68
Alina Rais, M.D. Associate Professor of Psychiatry Medical Director Geriatric Psychiatry Center University of Toledo Department of Psychiatry ASSESSMENT OF DEPRESSION IN THE ELDERLY

Alina Rais, M.D. Associate Professor of Psychiatry Medical Director Geriatric Psychiatry Center University of Toledo Department of Psychiatry ASSESSMENT

Embed Size (px)

Citation preview

Alina Rais, M.D.Associate Professor of Psychiatry

Medical Director Geriatric Psychiatry Center

University of ToledoDepartment of Psychiatry

ASSESSMENT OF DEPRESSION IN THE ELDERLY

Demographic of AgingDemographic of Aging

1900 – Only 4% were 65 and older1900 – Only 4% were 65 and older 2000 – Increased by 13% in elderly 2000 – Increased by 13% in elderly

populationpopulation 2050 – Projected increase of 22% in 2050 – Projected increase of 22% in

elderly populationelderly population

0

10

20

30

40

50

60

70

80

1900 1930 1960 1990 2025 2045

Millions

US Population: age 65 and over

Mental Health in the Mental Health in the ElderlyElderly

Elderly people have greater risk of Elderly people have greater risk of mental illnessmental illness

15-25% of elderly in the USA suffer 15-25% of elderly in the USA suffer from symptoms of mental illnessfrom symptoms of mental illness

Age 65 and older – highest suicide Age 65 and older – highest suicide riskrisk

MENTAL HEALTH IN THE MENTAL HEALTH IN THE ELDERLYELDERLY

Only 41% of the patients in Only 41% of the patients in community mental health are community mental health are elderlyelderly

Only 2% seen in hospital and Only 2% seen in hospital and private settingprivate setting

Only 1.5% of the direct costs for Only 1.5% of the direct costs for treating mental health are treating mental health are allocated for the elderlyallocated for the elderly

One of the most common mental One of the most common mental illnesses in the elderly is illnesses in the elderly is

Depression SyndromeDepression Syndrome which which includes the following symptoms:includes the following symptoms:

PhysicalPhysical EmotionalEmotional

CognitiveCognitive

The NIH ConsensusThe NIH Consensus

Depression: Depression: Affects 6 million people or 1 in 6Affects 6 million people or 1 in 6 Is not a normal fact of agingIs not a normal fact of aging Is associated with functional Is associated with functional

disability and suicidedisability and suicide Can alter the course of a general Can alter the course of a general

medical conditionmedical condition

The NIH ConsensusThe NIH Consensus (Cont.) (Cont.)

Depression:Depression: Increases morbidity and mortality Increases morbidity and mortality It is a recurrent illnessIt is a recurrent illness Occurs more frequently in nursing Occurs more frequently in nursing

homeshomes

Suicide in the ElderlySuicide in the Elderly

Elderly suicide up by 9% in the last Elderly suicide up by 9% in the last decadedecade

White males over 65 account for 81% White males over 65 account for 81% of all suicidesof all suicides

Profile for Highest Suicide Profile for Highest Suicide RiskRisk

White male over 60White male over 60 Divorced/single/widowDivorced/single/widow Poor social supportPoor social support UnemployedUnemployed Medical problemsMedical problems History of alcohol abuseHistory of alcohol abuse High school educationHigh school education Access to gunsAccess to guns

0

10

20

30

40

50

60

70

ToldPhysician

Counseling Medication ECT

Depression

Depression: Underrecognized and Undertreated in the Elderly

Pat

ient

s P

erce

nt (

%)

ECT=electroconvulsive therapyMaddux RE, Delrhim KK, Rapaport MH. CNS Spectr. Vol 8, No 12 (Suppl 3), 2003.

0

5

10

15

20

Visits LaboratoryTests

RadiologicalProcedures

Consultations Total

Depressed

Not Depressed

Health Services Utilization in Depressed Elderly Patients

*P,.001 after controlling for comorbidity, type of insurance, and the use of antidepressantsΥP=.008.N=3,481 primary care patients >65 years of ageAdapted from: Luber MP, Meyers BS, Williams-Russo PG, et al Depression and service utlization in elderly primary care patients. Am J Geriatr Psychiatry 2001:2:169-176Maddux RE, Delrahim KK, Rapaport MH. CNS Spectr. Vol 8, No 12 (Suppl 3). 2003.

Nu

mb

er

Ove

r 1

Ye

ar

0

10

20

30

40

50

60

70

80

10-14

20-24

30-34

40-44

50-54

60-64

70-74

80-84

Total

Male

Females

Rates of Completed Suicide

In the United States, 1994Per 100,000

Adapted from: Hirschfeld RM, Russell JM. Assessment and treatment of suicidal patients. N Engl J Med. 1997;13:910-913.

Num

ber

of S

uici

des

Prevalence of Late Life Prevalence of Late Life DepressionDepression

Elderly women are at increased riskElderly women are at increased risk Twice as many in women compared to men of Twice as many in women compared to men of

same agesame age Might be a subsyndromal presentation like Might be a subsyndromal presentation like

dysthymia, dysphoria dysthymia, dysphoria DSM IV – not age sensitiveDSM IV – not age sensitive 6%-9% of patients in primary setting6%-9% of patients in primary setting 17%-37% diagnosed with minor depression17%-37% diagnosed with minor depression 10-15% of patients in acute care10-15% of patients in acute care 30%-45% of patients in nursing homes30%-45% of patients in nursing homes 13% of residents in nursing homes who 13% of residents in nursing homes who

experience first episode of depressionexperience first episode of depression

Other Consequences of Other Consequences of Depression-PsychiatricDepression-Psychiatric

Increased use of alcohol and sedativesIncreased use of alcohol and sedatives Reduced cognitive functionReduced cognitive function

– Depressive “Pseudodementia”Depressive “Pseudodementia”– Excess disability in Alzheimer’s disease Excess disability in Alzheimer’s disease

and strokeand stroke Elevated nonsuicidal mortalityElevated nonsuicidal mortality

– In nursing homes – increased 59%In nursing homes – increased 59%– In MI patients-hazard ratio 5.74In MI patients-hazard ratio 5.74– In stroke, COPDIn stroke, COPD

External/Underlying factors (examples):Preclinical dementiaPovertyLow social supportMedical illness

Increased Risk for Incident Physical IllnessVascular disease (stroke, coronary artery disease)Cancer?Osteoporosis?Hip fracture

Health behaviors:Poor medication adherenceNon-adherence to visual or hearing aids?Smoking and physical inactivityPoor participation in rehabilitation

Features of the depressed state:Executive-type cognitive deficitsPoor appetite, causing low body mass indexPsychomotor retardationApathy and motivational deficitSleep disturbanceDecreased pain threshold

Sequelae of disability:Increased negative life eventsLoss of perceived controlLow self-esteemSocial activity restrictionStrained interpersonal relationships

DepressionPhysical Disability

Risk Factors in Development of Late Risk Factors in Development of Late Life DepressionLife Depression

(Biopsychosocial Illness Model)(Biopsychosocial Illness Model)

Biological Risk FactorsBiological Risk Factors

- Female > male- Female > male

- Changes in neurotransmitter activity- Changes in neurotransmitter activity

- Dysregulation of the HPA (hypothalamic,- Dysregulation of the HPA (hypothalamic,

pituitary axis)pituitary axis)

- Dysregulation of thyroid function- Dysregulation of thyroid function

- Decreased secretion of growth hormone- Decreased secretion of growth hormone

Risk Factors in Development Risk Factors in Development of Late Life Depressionof Late Life Depression(Biopsychosocial Illness (Biopsychosocial Illness

Model)Model)(Cont.)(Cont.)

Desynchronization of circadian Desynchronization of circadian rhythms with sleep cycle disturbancerhythms with sleep cycle disturbance

Physical aspects of medical illnessPhysical aspects of medical illness PolypharmacyPolypharmacy

Psychological Risk FactorsPsychological Risk Factors

Decreased social supportDecreased social support

Decreased functionality Decreased functionality

Placement in a nursing homePlacement in a nursing home

Life events, i.e. retirementLife events, i.e. retirement

Psychological Risk Factors Psychological Risk Factors

(Cont.)(Cont.) Changes in financial statusChanges in financial status

BereavementBereavement

History of mental illnessHistory of mental illness

Decreased self-esteemDecreased self-esteem

Diagnosing depression in the elderly Diagnosing depression in the elderly could be challengingcould be challenging

Elderly population received 20-30% Elderly population received 20-30% of all prescribed medicationsof all prescribed medications

Experience decline of cognitive and Experience decline of cognitive and functional capacityfunctional capacity

Barriers in Diagnosing Barriers in Diagnosing Depression in Elderly PatientsDepression in Elderly Patients

Most of this group of patients are seen in Most of this group of patients are seen in primary care settingsprimary care settings

Despite extensive education, still the family Despite extensive education, still the family doctors fail to diagnose depressiondoctors fail to diagnose depression

Different syndrome presentations ( not classical Different syndrome presentations ( not classical symptoms of depression, sad less depression)symptoms of depression, sad less depression)

Stigma Stigma Lack of recognition of depressive symptoms by Lack of recognition of depressive symptoms by

patient and family (seen as part of getting old)patient and family (seen as part of getting old)

When evaluating the elderly depressed When evaluating the elderly depressed patient, we need to:patient, we need to:– Identify any prior psychiatric illnessIdentify any prior psychiatric illness– Identify comorbid illnessesIdentify comorbid illnesses– Baseline medical historyBaseline medical history– Overall cognitive capacityOverall cognitive capacity– Identify current stressorsIdentify current stressors– Evaluate medication that might contribute to Evaluate medication that might contribute to

depressiondepression– Receive objective information from Receive objective information from

family/caregiverfamily/caregiver

Different Presentation of Different Presentation of DepressionDepression

Classic form of major depressive Classic form of major depressive disorder that meets the DSM IV-R disorder that meets the DSM IV-R criteriacriteria

Mask depression (somatic complaints, Mask depression (somatic complaints, anxiety)anxiety)

Subsyndromal presentation (minor Subsyndromal presentation (minor symptoms, dysthymia)symptoms, dysthymia)

Depression due to medical conditionDepression due to medical condition Vascular depressionVascular depression

DiagnosisDiagnosis MDDMDD

– Criteria for Depression DSM IV-TRCriteria for Depression DSM IV-TR 2 week period with 5 or more of the following with 1 2 week period with 5 or more of the following with 1

being either depressed mood or loss of interest/pleasurebeing either depressed mood or loss of interest/pleasure– Depressed mood most of the day/every day (subjective or Depressed mood most of the day/every day (subjective or

objective)objective)– Diminished interest/pleasure – anhedoniaDiminished interest/pleasure – anhedonia– Weight loss or gain >5% in a month or change in appetiteWeight loss or gain >5% in a month or change in appetite– Insomnia or hypersomnia nearly every dayInsomnia or hypersomnia nearly every day– Psychomotor retardation or agitation (objective)Psychomotor retardation or agitation (objective)– Loss of energy nearly every dayLoss of energy nearly every day– Worthlessness or guilt nearly every dayWorthlessness or guilt nearly every day– Decreased concentrationDecreased concentration– Suicidality/passive death wishSuicidality/passive death wish

Symptoms cause clinically significant distress or Symptoms cause clinically significant distress or impairmentimpairment

Symptoms are not better accounted for by another Symptoms are not better accounted for by another psych illnesspsych illness

Symptoms are not due to the direct physiological effects Symptoms are not due to the direct physiological effects of a substance or GMCof a substance or GMC

Minor DepressionMinor Depression

Subsyndromal presentation Subsyndromal presentation It is now introduced as a DSM IV categoryIt is now introduced as a DSM IV category Much more seen in community samplesMuch more seen in community samples It is considered to represent a spectrum: It is considered to represent a spectrum:

– Prodromal/residual symptoms of MDEProdromal/residual symptoms of MDE– Occurs in patients with underlying medical Occurs in patients with underlying medical

condition and dementing processescondition and dementing processes– The consequences on functional capacity are The consequences on functional capacity are

substantialsubstantial

Proposed Diagnostic CriteriaProposed Diagnostic Criteria 1) Presence of low mood and/or loss of interest in all activities 1) Presence of low mood and/or loss of interest in all activities

most of most of the day, nearly every day, andthe day, nearly every day, and 2) At least two additional symptoms from the DSM checklist:2) At least two additional symptoms from the DSM checklist:

a.a. Significant weight loss when not dieting or weight gain (e.g., a Significant weight loss when not dieting or weight gain (e.g., a change in more than 5% of body weight in 1 month), or change in more than 5% of body weight in 1 month), or decrease or increase in appetite nearly every daydecrease or increase in appetite nearly every day

b.b. Insomnia or hypersomnia nearly every day Insomnia or hypersomnia nearly every day c.c. Psychomotor retardation or agitation nearly every day Psychomotor retardation or agitation nearly every day

(observable by others, not merely subjective feelings of (observable by others, not merely subjective feelings of restlessness or being slowed down)restlessness or being slowed down)

d.d. Fatigue or loss of energy nearly every dayFatigue or loss of energy nearly every daye.e. Feelings of worthlessness or excessive or inappropriate guilt) Feelings of worthlessness or excessive or inappropriate guilt)

which may be delusional) nearly every day (not merely self-which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)reproach or guilt about being sick)

f.f. Diminished ability to think or concentrate, or indecisiveness, Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed nearly every day (either by subjective account or as observed by others)by others)

g.g. Recurrent thoughts of death (not just fear of dying), recurrent Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicidea specific plan for committing suicide

Proposed Diagnostic Criteria Proposed Diagnostic Criteria (Cont.)(Cont.)

3)3) The symptoms cause clinically significant The symptoms cause clinically significant distress or impairment in social and distress or impairment in social and occupational functioningoccupational functioning

4)4) 17 item Hamilton Rating Scale for 17 item Hamilton Rating Scale for Depression (Ham-D) score of Depression (Ham-D) score of >>10, or 10, or Geriatric Depression Scale Score of Geriatric Depression Scale Score of >>1212

5)5) Duration of at least 1 monthDuration of at least 1 monthDuration subtypes:Duration subtypes:

a.a. Duration from 1-6 monthsDuration from 1-6 monthsb.b. Duration from 6-24 monthsDuration from 6-24 monthsc.c. Duration >24 monthsDuration >24 months

Proposed Diagnostic Criteria Proposed Diagnostic Criteria (Cont.)(Cont.)

6)6) The symptoms may be associated with precipitaing The symptoms may be associated with precipitaing events (e.g., loss of significant other)events (e.g., loss of significant other)

7)7) Organic criteria:Organic criteria:- objective evidence from physical and neurological - objective evidence from physical and neurological examination and laboratory tests; and/or history of examination and laboratory tests; and/or history of cerebral disease, damage, or dysfunction, or of systemic cerebral disease, damage, or dysfunction, or of systemic physical disorder known to cause cerebral dysfunction; physical disorder known to cause cerebral dysfunction; including hormonal disturbances and drug effectsincluding hormonal disturbances and drug effects- a presumed relationship between the development or - a presumed relationship between the development or exacerbation of the underlying disease and clinically exacerbation of the underlying disease and clinically significant depressionsignificant depression- the disturbance occurs exclusively to the direct - the disturbance occurs exclusively to the direct psychological effect of alcohol or a substance usepsychological effect of alcohol or a substance use- recovery or significant improvement of the depressive - recovery or significant improvement of the depressive symptoms following removal or improvement of the symptoms following removal or improvement of the underlying presumed causeunderlying presumed cause

Proposed Diagnostic Criteria Proposed Diagnostic Criteria (Cont.)(Cont.)

8) Exclusion criteria:8) Exclusion criteria:

There has never been:There has never been:

an episode or mania or hypomania;an episode or mania or hypomania;

a chronic psychotic disorder, such as a chronic psychotic disorder, such as schizophrenia or delusional schizophrenia or delusional disorders. Previous history of major disorders. Previous history of major depressive episode is not an depressive episode is not an exclusion criterion. exclusion criterion.

Depression and Medical IllnessDepression and Medical Illness

Medical illness greatly increases riskf or Medical illness greatly increases riskf or depressiondepression

Risk to particularly high inRisk to particularly high in– Ischemic heart disease (e.g., MI, CABG)Ischemic heart disease (e.g., MI, CABG)– StrokeStroke– CancerCancer– Chronic lung diseaseChronic lung disease– ArthritisArthritis– Alzheimer’s diseaseAlzheimer’s disease– Parkinson’s diseaseParkinson’s disease

Mechanisms of depression varyMechanisms of depression vary Medical Illness may confuse the diagnosis of Medical Illness may confuse the diagnosis of

depression in medical patientsdepression in medical patients

Depression Due to Medical Depression Due to Medical ConditionCondition

Older age of onsetOlder age of onset Organic features on MSEOrganic features on MSE Lower incidence of family hx of Lower incidence of family hx of

depressiondepression Less likely to have SI/HI Less likely to have SI/HI More likely to improve at dischargeMore likely to improve at discharge Higher morbidity and mortality in Higher morbidity and mortality in

CAD, MI and CVACAD, MI and CVA Atypical presentationAtypical presentation

Medications Associated With Medications Associated With Depression and AnxietyDepression and Anxiety

AnticancerAnticancer Cimetidine, cyclotherine, other, levodopa, Cimetidine, cyclotherine, other, levodopa, ranitidineranitidine

AnticholinergicAnticholinergic Amopine, benztropine, hycosamine, Amopine, benztropine, hycosamine, probanthineprobanthine

Anti-inflammatory/ anti-infectiveAnti-inflammatory/ anti-infective Baclofen, disulfirma, ethambutol, fenoprofen, Baclofen, disulfirma, ethambutol, fenoprofen, indomethacin, naproxen, phenylbutazone, indomethacin, naproxen, phenylbutazone, sulfonamidessulfonamides

CardiovascularCardiovascular Bethanidine, clonidine, diuretics, guanethidine, Bethanidine, clonidine, diuretics, guanethidine, hydralazine, methyldopa, propranolol, hydralazine, methyldopa, propranolol, reserpine, thiazidereserpine, thiazide

HormonesHormones Anabolic steroids, corticotrophin, estrogen Anabolic steroids, corticotrophin, estrogen hormone blocker, glucocorticoids, oral hormone blocker, glucocorticoids, oral contraceptivescontraceptives

PsychotropicsPsychotropics Benzodiazepines, neurolepticsBenzodiazepines, neuroleptics

StimulantsStimulants Caffeine, nicotineCaffeine, nicotine

SympathomimeticsSympathomimetics Appetite suppressants, ephedrine, Appetite suppressants, ephedrine, pseudoephedrinepseudoephedrine

Withdrawal from:Withdrawal from: Alcohol, amphetamines, cocaine, hypnotics, Alcohol, amphetamines, cocaine, hypnotics, sedativessedatives

Maddux RE, Delrahim KK, Ra[a[prt <J/ CMS S[ectr/ V

Maddux RE, De;rajo, LL. Ra[a[prt <J. CMS S[pectr/ Vp; 8, No 12 (Suppl 3). 2003.

Drugs Linked to Drugs Linked to Depression/AnxietyDepression/Anxiety

Beta-blockersBeta-blockers Other antihypertensivesOther antihypertensives ReserpineReserpine DigoxiaDigoxia L-DopaL-Dopa SteroidsSteroids BenzodiazepinesBenzodiazepines PhenobarbitalPhenobarbital NeurolepticsNeuroleptics

““Masked” DepressionMasked” Depression

Terminal insomnia, often with ruminationsTerminal insomnia, often with ruminations Decreased appetite and weight lossDecreased appetite and weight loss Extreme fatigue vs. anxiousness, restlessnessExtreme fatigue vs. anxiousness, restlessness Increased, frequently delusional, preoccupation Increased, frequently delusional, preoccupation

with bodily functions, pain and weaknesswith bodily functions, pain and weakness Expression of fears and anxiety without reasonExpression of fears and anxiety without reason Low self-esteem or self-conceptLow self-esteem or self-concept Increased isolation, loss of interest and pleasureIncreased isolation, loss of interest and pleasure Hopelessness, suicidal ideationHopelessness, suicidal ideation

– All in context of “not feeling well physically”All in context of “not feeling well physically”– Depression is felt to be “secondary”Depression is felt to be “secondary”

Clues to Depression in Primary Clues to Depression in Primary CareCare

Help-seeking, persistent complaintsHelp-seeking, persistent complaints

• Frequent calls and visits• High utilization of services•Treatment refusal, non-compliance

Pain GI SymptomsArthritis Multiple diffuse symptomsWeight Loss HeadacheInsomnia

Additional Clues in Nursing Additional Clues in Nursing HomeHome

Apathy, withdrawal, isolationApathy, withdrawal, isolation Failure to thriveFailure to thrive AgitationAgitation Delayed rehabilitationDelayed rehabilitation

Additional Clues in Hospitalized Additional Clues in Hospitalized PatientsPatients

CABG, hip fracture, MI, stroke, CABG, hip fracture, MI, stroke, arthritisarthritis

Delayed recoveryDelayed recovery Treatment refusalTreatment refusal Discharge problemDischarge problem

Chronic Pain and Chronic Pain and DepressionDepression

Study of more than 1000 patients Study of more than 1000 patients found depression in 1% of patients found depression in 1% of patients with one or no pain complaintswith one or no pain complaints

12% in patients with 3 or more such 12% in patients with 3 or more such complaintscomplaints

Depression and Depression and Neurodegenerative Brain Neurodegenerative Brain

DiseaseDisease Alzheimer’s Dementia Alzheimer’s Dementia Vascular Dementia/Cerebrovascular Vascular Dementia/Cerebrovascular

DiseaseDisease– ApathyApathy– Nondysphoric DepressionNondysphoric Depression

Parkinson’s DiseaseParkinson’s Disease

Vascular DepressionVascular Depression

Cerebrovascular disease can:Cerebrovascular disease can:

- predispose- predispose

- precipitate - precipitate

- perpetuate - perpetuate

- a depressive syndrome- a depressive syndrome

Risk Factors of Vascular Risk Factors of Vascular DepressionDepression

Male gender Male gender Older ageOlder age Diabetes MellitusDiabetes Mellitus SmokingSmoking

Risk Factors of Vascular Risk Factors of Vascular Depression (Cont.) Depression (Cont.)

Atrial fibrillationAtrial fibrillation Left Ventricular Hypertrophy Left Ventricular Hypertrophy Higher systolic blood pressureHigher systolic blood pressure Angina Pectoris Angina Pectoris Congestive Heart FailureCongestive Heart Failure

Cerebrovascular Evidence in Cerebrovascular Evidence in Late Life DepressionLate Life Depression

Genetic and early life stressors Genetic and early life stressors less importantless important

Diffuse brain dysfunction Diffuse brain dysfunction Cortical atrophyCortical atrophy Diffuse hypometabolismDiffuse hypometabolism

Cerebrovascular Evidence in Cerebrovascular Evidence in Late Life Depression (Cont.)Late Life Depression (Cont.)

Deep white and gray matter Deep white and gray matter hyperintensities on MRIhyperintensities on MRI

Small vessel disease postmortem Small vessel disease postmortem Relation between stroke and Relation between stroke and

depressiondepression

Localization of Brain Localization of Brain DiseaseDisease

in Depressionin Depression

Hyperintensities in: Hyperintensities in:

- left hemisphere deep white matter- left hemisphere deep white matter

- left putamen- left putamen

Localization of Brain DiseaseLocalization of Brain Disease in Depression in Depression

(Cont.)(Cont.)• Lesions of:

- caudate

- frontal lobe

- basal ganglia

Brain Function EvidenceBrain Function Evidence

Hypoactivity of the caudate and Hypoactivity of the caudate and frontal regions including frontal regions including

- dorsolateral frontal region- dorsolateral frontal region

- inferior orbitofrontal region- inferior orbitofrontal region

- medial anterior cingulate - medial anterior cingulate

Summary of Vascular Summary of Vascular Mechanisms of Late-Life Mechanisms of Late-Life

DepressionDepression Small lesions disrupt critical pathways:Small lesions disrupt critical pathways:

- frontostriatal, circuitry and limbic- frontostriatal, circuitry and limbic

hippocampal connectionshippocampal connections

- damage of the catecholamine neurons by - damage of the catecholamine neurons by

white matter lesions in the ponswhite matter lesions in the pons

- Disruption of the orbital frontal cortex - Disruption of the orbital frontal cortex controlcontrol

over the serotonergic raphe nuclei over the serotonergic raphe nuclei

Symptoms and PresentationSymptoms and Presentation

Increased psychomotor retardation Increased psychomotor retardation

More prominent cognitive More prominent cognitive impairmentimpairment

Poor performance on Poor performance on neuropsychological testsneuropsychological tests

Symptoms and PresentationSymptoms and Presentation (Cont.) (Cont.)

Less agitation and guilt Less agitation and guilt Increased disabilityIncreased disability Older age of onsetOlder age of onset Executive dysfunction and apathyExecutive dysfunction and apathy

Two Major Behavioral Two Major Behavioral Symptoms in Late-LifeSymptoms in Late-Life

- Apathy - Apathy

- Executive Function- Executive Function

ApathyApathy

A state of reduced motivation.

Types of ApathyTypes of Apathy

Motor apathyMotor apathy

- Tendency not to initiate motor activity- Tendency not to initiate motor activity Motivational apathyMotivational apathy

- Absence of motivation to initiate new - Absence of motivation to initiate new activitiesactivities

Emotional apathyEmotional apathy

- Absence or reduction of emotional interest- Absence or reduction of emotional interest Cognitive apathyCognitive apathy

- Absence of generative ideation- Absence of generative ideation

Conditions Associated with Conditions Associated with Syndrome of ApathySyndrome of Apathy

Alzheimer’s DiseaseAlzheimer’s Disease Vascular DiseaseVascular Disease Brain DamageBrain Damage Partially treated depressionPartially treated depression Psychotic depressionPsychotic depression SchizophreniaSchizophrenia Drug-induced (neuroleptics, SSRI’s, marijuana, Drug-induced (neuroleptics, SSRI’s, marijuana,

amphetamine or cocaine withdrawal)amphetamine or cocaine withdrawal) Other: apathetic hyperthyroidism, lyme dz, Other: apathetic hyperthyroidism, lyme dz,

chronic fatigue, testosterone deficiency, sleep chronic fatigue, testosterone deficiency, sleep apnea, etc.apnea, etc.

Executive DysfunctionExecutive Dysfunction

Decreased:

• attention

• initiation

• organization

• planning

• abstract thinking

Screening for DepressionScreening for Depression

Evidence-based literature is Evidence-based literature is somewhat sparse and at times somewhat sparse and at times conflictingconflicting

Majority of physicians would rely on Majority of physicians would rely on individual judgment when assessing individual judgment when assessing depression in the elderlydepression in the elderly

Overview of Currently Used Overview of Currently Used Depression Scales in Geriatric Depression Scales in Geriatric

PatientsPatients When using screening instruments in When using screening instruments in

elderly patients it is important to elderly patients it is important to consider the cognitive levelconsider the cognitive level– Visual auditory deficits Visual auditory deficits – Function levelFunction level

The validity of certain depression The validity of certain depression screening instruments is significantly screening instruments is significantly decreased in patients with MMSE decreased in patients with MMSE lower or equal to 15lower or equal to 15

Geriatric Depression Scale Geriatric Depression Scale (GDS)(GDS)

30 questions that indicate presence of depression30 questions that indicate presence of depression Yes/No formatYes/No format Might be more appropriate for elderly patientsMight be more appropriate for elderly patients Sensitivity 92% Sensitivity 92% Specificity 89%Specificity 89% Valid measure of depression in elderly patientsValid measure of depression in elderly patients Validity decreases in nursing home patients and Validity decreases in nursing home patients and

appears to be dependent on the degree of appears to be dependent on the degree of cognitive impairmentcognitive impairment

Can be used in inpatient and outpatientCan be used in inpatient and outpatient Very reliable for phone screeningVery reliable for phone screening Available for minoritiesAvailable for minorities

Depression Scale for People Depression Scale for People with Dementia (Cornell Scale with Dementia (Cornell Scale for Depression in Dementia or for Depression in Dementia or

CSDD)CSDD) Best validated scale for patients with Best validated scale for patients with

dementiadementia Use information from both patients Use information from both patients

and outside informantand outside informant Better validated for patients with mild Better validated for patients with mild

and moderate dementia than with and moderate dementia than with severe formsevere form

Could depict depression in patients Could depict depression in patients with Alzheimer's. with Alzheimer's.

Montgomery/Asperg Montgomery/Asperg Depression Rating Scale Depression Rating Scale

(MADRS)(MADRS)

Observer rated assessmentObserver rated assessment Based on clinical interviewBased on clinical interview Does not assess somatic symptoms Does not assess somatic symptoms

that are important in geriatric that are important in geriatric populationpopulation

Not very well validated in geriatric Not very well validated in geriatric patientspatients

Zung Self-Rating Depression Zung Self-Rating Depression Scale Scale

Self assessment scaleSelf assessment scale Uses graded answers (never, Uses graded answers (never,

sometimes, always, usually which sometimes, always, usually which might be problematic for geriatric might be problematic for geriatric patients)patients)

High false positive results in normal High false positive results in normal elderlyelderly

High false negative results if patients High false negative results if patients has somantic problemshas somantic problems6262

Beck Depression Inventory Beck Depression Inventory (BDI)(BDI)

Developed by Beck, Steer & BrownDeveloped by Beck, Steer & Brown Assesses the intensity of depressive Assesses the intensity of depressive

symptomssymptoms 5-10 minutes to administer5-10 minutes to administer Highly reliable regardless of the Highly reliable regardless of the

population testedpopulation tested Available in SpanishAvailable in Spanish

Hamilton Rating Scale for Hamilton Rating Scale for DepressionDepression

Goal standard of observer-rated Goal standard of observer-rated depression scaledepression scale

Requires training to completeRequires training to complete Takes 20-25 minutes to administerTakes 20-25 minutes to administer Valid for all agesValid for all ages Can be used in both clinical and Can be used in both clinical and

researchresearch Assesses the severity of depressionAssesses the severity of depression

ELDERLYBeck DepressionInventory (BDI)

Yes 21 5 to 10 Alpha:0.76/above 15

Center for Epidemiological Studies Depression Scale (CES-D)

Yes 20 5 to 10 Sensitivity: 92%Specificity:87%/above 15

Cornell Scale for Depression in Dementia

NO 19 10 with patient, 20 with caregiver

Sensitivity: 90%Specificity:75%/above 12

Geriatric Depression Scale (GDS)

Yes 30 10 to 15 Specificity:100%/above 13Sensitivity: 92% to 97%

Geriatric Depression Scale-short

Yes 15 5 to 10 Specificity: 64.8% to 81%/above 5

Zung Depression Rating Scale

No 20 5 to 10 Specificity: 63%/above 49

Screening Measures for Depression in Children, Adolescents, Adults, and the Elderly

Measure Spanish Version No of Items Time to Complete Psychometric properties/cutoff

Selective Serotonin ReuptakeInhibitorsCitalopramFluoxetineParoxetineSertralineTrazodone

10-40 mg/day10-40 mg/day10-40 mg/day25-100 mg/day25-150 mg/day

Depression, Dysthymia, anxietyCommon to all SSRIsCommon to all SSRIsCommon to all SSRIsWhen sedation is desirable

GI upset, nausea, vomiting, insomnia

Sedation, falls, hypotension

Tricyclic AntidepressantsDesipramine

Nortriptyline

10-100 mg/day

10-75 mg/day

Adjunctive pain management/ neuropathic painHigh efficacy for depression if patient can tolerate side effects

Anticholinergic effects, hypotension, sedation, cardiac arrhythmias

Other AgentsBuproprion

MirtazapineNefazodone

Vanlafaxine

75-225 mg/day

7.5-30 mg/day50-200 mg/day

25-150 mg/day

More activating, lack of cardiac effectsUseful for insomniaUseful for insomnia

Useful in severe depression

Irritability, insomnia

Sedation, hypotensionSedation, hypotension*Warning, do not use in

liver diseaseHypertension may be a

problem; insomnia

PsychostimulantsMethylphenidate

Dextroamphetamine

2.5-20 mg/dayGive before 1PM

2.5-15 mg/dayGive before 1PM

Ofen rapid onsetmay augment antidepressants

Same as above

Tachycardia, irritability, tremor, excitation, insomnia

Similar, but possibly More over-stimulation

Medications Useful in Treating DepressionMedication Doses Ranger Uses Precautions

Selective Serotonin ReuptakeInhibitorsCitalopramFluoxetineParoxetineSertralineTrazodone

10-40 mg/day10-40 mg/day10-40 mg/day25-100 mg/day25-150 mg/day

Depression, Dysthymia, anxietyCommon to all SSRIsCommon to all SSRIsCommon to all SSRIsWhen sedation is desirable

GI upset, nausea, vomiting, insomnia

Sedation, falls, hypotension

Tricyclic AntidepressantsDesipramine

Nortriptyline

10-100 mg/day

10-75 mg/day

Adjunctive pain management/ naturopathic painHigh efficacy for depression if patient can tolerate side effects

Anticholinergic effects, hypotension, sedation, cardiac arrhythmias

Other AgentsBuproprion

MirtazapineNefazodone

Vanlafaxine

75-225 mg/day

7.5-30 mg/day50-200 mg/day

25-150 mg/day

More activating, lack of cardiac effectsUseful for insomniaUseful for insomnia

Useful in severe depression

Irritability, insomnia

Sedation, hypotensionSedation, hypotension*Warning, do not use in

liver diseaseHypertension may be a

problem; insomnia

PsychostimulantsMethylphenidate

Dextroamphetamine

2.5-20 mg/dayGive before 1PM

2.5-15 mg/dayGive before 1PM

Ofen rapid onsetmay augment antidepressants

Same as above

Tachycardia, irritability, tremor, excitation, insomnia

Similar, but possibly More over-stimulation

Psychosocial Interventions for Psychosocial Interventions for DepressionDepression

Social support to reduce isolation; referral to senior Social support to reduce isolation; referral to senior centers, home care, and visiting nurse services; centers, home care, and visiting nurse services; pet therapy and visitation; volunteer jobs as pet therapy and visitation; volunteer jobs as indicatedindicated

Psychotherapy: supportive psychotherapy, Psychotherapy: supportive psychotherapy, cognitive-behavioral therapy, interpersonal cognitive-behavioral therapy, interpersonal therapy, group therapytherapy, group therapy

Family counselingFamily counseling Substance abuse interventions as indicatedSubstance abuse interventions as indicated Bereavement counseling and services as neededBereavement counseling and services as needed Health promotion and maintenance: good nutrition, Health promotion and maintenance: good nutrition,

light physical exercise, attention to chronic medical light physical exercise, attention to chronic medical conditions, establish a regular daily routineconditions, establish a regular daily routine

ConclusionConclusion

When diagnosing depression in geriatric When diagnosing depression in geriatric patients, there are 5 essential objectives:patients, there are 5 essential objectives:– Determine etiology and diagnosisDetermine etiology and diagnosis– Provide disease specific managementProvide disease specific management– Manage behaviors and target symptoms Manage behaviors and target symptoms

(symptoms that are the most distressing)(symptoms that are the most distressing)– Prevent secondary complications (side effects Prevent secondary complications (side effects

of medication)of medication)– Rule out dementing process/medical illnessRule out dementing process/medical illness– Support the familiesSupport the families