1. Click here to go to the OIG's March 2003 report on SNF's Psychosocial shortcomings

2. Click here to go to the Surgeon General's report on Mental Health

3. Click here to read Providers Magazine article on Mental Health (June 2003)

4. American Geriatrics Society and American Association for Geriatric Psychiatry

5. The Effect of a Primary Care Practice–Based Depression Intervention on Mortality in Older Adults

6. Assessment and Treatment of Nursing Home Residents with Depression or Behavioral Symptoms Associated with Dementia: A Review of the Literature

7. Depression can trigger diabetes in seniors

8. Psychological Issues in Pain Perception and Treatment in the Elderly

9. Consensus Statement on Improving the Quality of Mental Health Care in U.S. Nursing Homes: Management of Depression and Behavioral Symptoms Associated with Dementia

10. REM Treatment

11. Understand Difficult Behaviors

12. Many seniors in long-term care depressed

13. A Nursing Home Shrinks Until It Feels Like a Home

14. Some Nursing Home Elderly Get Futile Care

15. Experiencing Life, Briefly, Inside a Nursing Home

16. CMS Announces New Demonstrations to Help Curb Improper Medicare, Medicaid Payments

17. Group activities improve mental function in mild to moderate dementia, study finds

18. Clearing the fog

19. Study nursing home

20. 2012 Group activities improve mental function in mild to moderate dementia.pdf

21. Screening for Suicidal Risk during brief Medical Management visit.pdf


Study. Yahoo!

Depressed Elderly Fail To Get Better

July 17, 2002
Section: News

The most recent issue of the Archives of Geriatric Psychiatry reports that depression in the elderly often remains unrecognized and untreated. In the six-year study, 14 percent of elderly participants diagnosed with depression had short-lived symptoms. Twenty-three percent had recurrent episodes. Depression is a common disease of the elderly and is highly treatable at any age.

Click here to read the entire article

New York Times Article:

In a First, Medicare Coverage Is Authorized for Alzheimer's

By Robert Pear

WASHINGTON, March 30 — The Bush administration, in a major change, has authorized Medicare coverage for the treatment of Alzheimer's disease, which afflicts nearly four million Americans and is expected to grow to epidemic proportions with the aging of the population.

The new policy means that Medicare beneficiaries can no longer be denied reimbursement for the costs of mental health services, hospice care or home health care just because they have Alzheimer's.

In the past, many claims were automatically denied on the assumption that treatment was futile because people with Alzheimer's were incapable of any medical improvement. Now, federal officials say, new studies show that people with Alzheimer's can often benefit from psychotherapy, physical and occupational therapy and other services.

"This is great news for people with Alzheimer's disease and other dementias," said Stephen R. McConnell, chief executive of the Alzheimer's Association. "The new policy should eliminate a form of discrimination against millions of people."

Neither federal officials nor advocates for the elderly provided estimates of the cost of the new policy. Experts said the direct cost to Medicare could be several billion dollars a year. But, they said, some of the cost could be offset by savings elsewhere in Medicare and Medicaid, because the new services will enable patients to live longer on their own, with greater ability to function.

The policy is set forth in a memorandum sent late last year from the government to the companies that review and pay Medicare claims. These companies have just begun to put the change into practice.

The government gave no public notice of the new policy, but it has already made a difference in the lives of some people with Alzheimer's. Some patients have received benefits that were once denied, and some medical practitioners have secured payment for services that Medicare once refused to cover.

The companies that review claims for the government, under federal contracts, are known as Medicare carriers. Most of them had programmed their computers to reject claims for people with Alzheimer's and other types of dementia. The new policy bans such computer software instructions and says contractors cannot deny claims simply because a person has Alzheimer's.


Betty Ferguson, right with her daughter, Jane Niederbrach, is among millions of Americans with Alzheimer's disease.

So is Harry Baker, whose daughter,
Jenni Lee Robins, holds his photograph.


"Throughout the course of their disease," the memorandum says, "patients with dementia may benefit from pharmacologic, physical, occupational, speech-language and other therapies."

Patients' advocates, including the Alzheimer's Association and the American Bar Association, had supplied the government with dozens of research studies providing scientific evidence that such therapies were effective.

The government said it changed its policy because doctors and psychologists can now often diagnose Alzheimer's in its early stages, when patients are most likely to derive significant benefits from treatment and therapy. While there is no cure for Alzheimer's, staving off its worst effects can prolong a relatively normal life and save money.

It is not clear why the government did not publicize the new policy. Some officials apparently did not want to acknowledge that the old policy was, in effect, biased against people with Alzheimer's. When asked, a Medicare official said the change was not announced because "we saw it mainly as a technical matter for Medicare carriers."

Mr. McConnell of the Alzheimer's Association estimated that 10 percent of people over 65 and nearly half of those over 85 had Alzheimer's, a brain disorder that causes loss of memory, changes in personality and behavior, and a decline in thinking abilities.

Under the policy, Medicare will pay for more therapy and outpatient services. Dr. Steven T. DeKosky, a neurologist who directs the Alzheimer's Disease Research Center at the University of Pittsburgh, said these services would "keep people out of nursing homes," avoiding costs that would otherwise be borne by the government, patients or their families.

Kim A. Warchol, an occupational therapist in Itasca, Ill., who specializes in the treatment of people with Alzheimer's, said the new policy had major implications for patients, their spouses and their children.

"People with Alzheimer's will be able to live at home longer and avoid institutionalization," Ms. Warchol said. "Caregivers often assume that people with Alzheimer's are helpless. But we focus on their remaining physical and mental abilities, the things they can still do, and we find that many patients can perform activities of daily living if we provide appropriate cues or reminders of how to get started. They can dress themselves or groom themselves if you lay out their clothing or grooming supplies."

Margaret P. Norris, an associate professor of psychology at Texas A&M University, said that while Alzheimer's was irreversible and incurable, patients with mild to moderate forms of the disease could benefit from psychotherapy to help them cope with loss of memory and with feelings of depression and anxiety.

"We encourage patients to keep a notebook full of important information, like the names of their grandchildren, which they might forget," Ms. Norris said. "In later stages of Alzheimer's disease, it's common for patients to yell and scream and become aggressive. That may be because the environment is too noisy and distracting. We can sometimes modify the patient's behavior by changing the environment."

The impact of the new policy is illustrated by the experience of Jenni Lee Robins, 58, of Winter Haven, Fla., who used it to get treatment for her father, Harry H. Baker.

Mr. Baker, 78, has had Alzheimer's for eight years. After he was hospitalized and admitted to a nursing home last year, he received physical therapy, but it was ended after the nursing home concluded that his condition would not improve. He was hospitalized this year for pneumonia.

After learning of the new policy from a local chapter of the Alzheimer's Association, Ms. Robins used it to ensure that her father got "all the appropriate therapies" — physical, occupational and respiratory.

"Daddy has improved tremendously because of the therapies Medicare now covers," Ms. Robins said. "He is in better condition now than before he went into the hospital this year. After eight days in the hospital, he lost the ability to walk, forgot how to walk. But after nine weeks of physical therapy, he can walk again."

People with Alzheimer's live an average of 8 to 10 years after the condition is diagnosed.

Dr. Paula E. Hartman-Stein, a clinical psychologist and founder of the Center for Healthy Aging in Kent, Ohio, said: "Previously, in many parts of the country, if a person had a diagnosis of dementia, the Medicare carrier would just arbitrarily, as a blanket policy, not cover psychological services. The new policy breaks down one of the major barriers to providing mental health services to elderly people."

Christina A. Metzler, director of federal affairs at the American Occupational Therapy Association, said the new policy was "tremendously significant" for patients. "In the past," she said, "a diagnosis of Alzheimer's could prevent a patient from getting Medicare coverage for therapy to treat other conditions — a broken hip, a broken wrist or a stroke."

The new policy was adopted after two years of lobbying by the Alzheimer's Association and the American Bar Association's Commission on Legal Problems of the Elderly.

Leslie B. Fried, a lawyer at the commission, used the Freedom of Information Act to get copies of the local rules used by Medicare carriers in deciding whether to pay claims. These documents, she said, showed that "people with Alzheimer's were often being denied medically necessary services."

Wall Street Journal Article:

Medication and Psychotherapy Help Elderly Fight Depression, Study Says

By Ron Winslow
Staff Reporter of THE WALL STREET Journal

A new study suggests that a combination of medication and talk therapy can yield striking results for elderly patients suffering from major depression.

Researchers at the University of Pittsburgh Medical Center, in a study involving 107 patients, found that just 20% of those taking an antidepressant called nortriptyline with monthly psychotherapy visits suffered recurrent bouts of depression within three years of an initial episode compared with 90% given a placebo without psychotherapy.

Those on the combination treatment also fared significantly better than two other groups of patients treated with either, the drug or talk therapy alone.

The findings come amid escalating interest about the impact of depression in the elderly. Some estimates are that about 15% of older Americans suffer from depression, but relatively few are appropriately diagnosed and treated. Other research shows that people with: depression have significantly higher medical costs than those without depression, indicating that better treatment of such mental afflictions, including among the elderly, could reduce the need for other health care.

"The good news is that, notwithstanding the burden of chronic mental illness, depression is treatable," said Charles F. Reynolds III, professor of psychiatry and neuroscience at the University of Pittsburgh and lead author of the new study. He said the beneficial effects of psychotherapy shown in the study particularly surprised him. About 57 % of patients given the drug alone were able to fend off depression for three years, compared with 80% on both the drug and psychotherapy and 36% on psychotherapy with placebo. "What really comes out is the advantage for combined treatment," he said.

The report, funded by the National Institute of Mental Health, appears in today's Journal of the American Medical Association.

Nortriptyline is one of a class of antidepressants known as tricyclics that were the, leading treatment for depression before Prozac and other so-called selective serotonin reuptake inhibitors, SSRl's, became popular during the past decade. Dr. Reynolds said the study, the first randomized trial to compare various treatment strategies against a placebo for depression in the elderly, was launched in 1989, before the new class of medicines became well established. He said his research group is now testing SmithKline Beecham PLC's SSRI, Paxil, in a trial similar to the current study. Nortriptyline is marketed as Pamelor by Novartis AG, and in generic forms by two other companies. Dr. Reynolds said the study wasn't funded by any pharmaceutical companies.

The findings serve to underscore some barriers to effective treatment for depression in the elderly. Traditional Medicare reimbursement doesn't cover prescription drugs, and Dr. Reynolds noted that both Medicare and managed health-care plans that serve Medicare patients tend to limit psychotherapy visits.

"We would like to argue that investing a little bit of resources to help older people wrestle with depression, bereavement and issues such as retirement may be very good for the national health care budget," he said. Adequate diagnosis of depression in the elderly is also hampered by the fact that visits with primary-care doctors often are so rushed that mental problems aren't detected or addressed. Diagnosis is also hampered by the reluctance of many elderly patients to acknowledge that they have depression and agree to treatment, experts say.

Associated Press Article:

Psychotherapy Best for Insomnia in Elderly

By Brenda C. Coleman
The Associated Press

CHICAGO - Older people with Insomnia got more long-term sleep improvement from eight weeks of psychotherapy than they did from eight weeks of sleeping pills or from a combination of the two, a study found.

The psychotherapy - called cognitive behavioral therapy involves changing people's habits, such as spending too much time in bed, as well as their erroneous beliefs, such as, the notion that everyone needs eight hours of sleep. "With eight treatment sessions, most of the time, I think we can help people," said Charles Morin, a clinical psychologist at Laval University in Quebec.

His study was published in Wednesday's Journal of the American Medical Association. The researchers studied 78 adults whose average age was 65 and whose chronic insomnia was not caused by any underlying physical problem. Morin said similar research in younger adults has had the same outcome.

The subjects were divided into four groups: one received 90 minutes a week of group therapy another received eight weeks of treatment with a prescription sleeping pill; a third got an eight week combination of therapy and sleeping pills; the fourth received a dummy pill. After two years, "only behavioral treatment provided durable changes," the researchers said.


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