ASSESSMENT OF DEPRESSION
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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. Demographic of Aging. 1900 – Only 4% were 65 and older 2000 – Increased by 13% in elderly population

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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


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Demographic of Aging

  • 1900 – Only 4% were 65 and older

  • 2000 – Increased by 13% in elderly population

  • 2050 – Projected increase of 22% in elderly population



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Mental Health in the Elderly

  • Elderly people have greater risk of mental illness

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

  • Age 65 and older – highest suicide risk


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MENTAL HEALTH IN THE ELDERLY

  • Only 41% of the patients in community mental health are elderly

  • Only 2% seen in hospital and private setting

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


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One of the most common mental illnesses in the elderly is Depression Syndrome which includes the following symptoms:

Physical

Emotional

Cognitive


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The NIH Consensus

Depression:

  • Affects 6 million people or 1 in 6

  • Is not a normal fact of aging

  • Is associated with functional disability and suicide

  • Can alter the course of a general medical condition


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The NIH Consensus (Cont.)

Depression:

  • Increases morbidity and mortality

  • It is a recurrent illness

  • Occurs more frequently in nursing homes


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Suicide in the Elderly

  • Elderly suicide up by 9% in the last decade

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


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Profile for Highest Suicide Risk

  • White male over 60

  • Divorced/single/widow

  • Poor social support

  • Unemployed

  • Medical problems

  • History of alcohol abuse

  • High school education

  • Access to guns


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Depression: Underrecognized and

Undertreated in the Elderly

Patients Percent (%)

ECT=electroconvulsive therapy

Maddux RE, Delrhim KK, Rapaport MH. CNS Spectr. Vol 8, No 12 (Suppl 3), 2003.


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Health Services Utilization in Depressed

Elderly Patients

Number Over 1 Year

*P,.001 after controlling for comorbidity, type of insurance, and the use of antidepressants

ΥP=.008.

N=3,481 primary care patients >65 years of age

Adapted from: Luber MP, Meyers BS, Williams-Russo PG, et al Depression and service utlization in elderly primary care patients. Am J Geriatr Psychiatry 2001:2:169-176

Maddux RE, Delrahim KK, Rapaport MH. CNS Spectr. Vol 8, No 12 (Suppl 3). 2003.


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Rates of Completed Suicide

Number of Suicides

In the United States, 1994

Per 100,000

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


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Prevalence of Late Life Depression

  • Elderly women are at increased risk

  • Twice as many in women compared to men of same age

  • Might be a subsyndromal presentation like dysthymia, dysphoria

  • DSM IV – not age sensitive

  • 6%-9% of patients in primary setting

  • 17%-37% diagnosed with minor depression

  • 10-15% of patients in acute care

  • 30%-45% of patients in nursing homes

  • 13% of residents in nursing homes who experience first episode of depression


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Other Consequences of Depression-Psychiatric

  • Increased use of alcohol and sedatives

  • Reduced cognitive function

    • Depressive “Pseudodementia”

    • Excess disability in Alzheimer’s disease and stroke

  • Elevated nonsuicidal mortality

    • In nursing homes – increased 59%

    • In MI patients-hazard ratio 5.74

    • In stroke, COPD


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Physical

Disability

Depression


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Risk Factors in Development of Late Life Depression(Biopsychosocial Illness Model)

  • Biological Risk Factors

    - Female > male

    - Changes in neurotransmitter activity

    - Dysregulation of the HPA (hypothalamic,

    pituitary axis)

    - Dysregulation of thyroid function

    - Decreased secretion of growth hormone


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Risk Factors in Development of Late Life Depression(Biopsychosocial Illness Model)(Cont.)

  • Desynchronization of circadian rhythms with sleep cycle disturbance

  • Physical aspects of medical illness

  • Polypharmacy


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Psychological Risk Factors

  • Decreased social support

  • Decreased functionality

  • Placement in a nursing home

  • Life events, i.e. retirement


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Psychological Risk Factors (Cont.)

  • Changes in financial status

  • Bereavement

  • History of mental illness

  • Decreased self-esteem


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Barriers in Diagnosing Depression in Elderly Patients (Cont.)

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

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

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

  • Stigma

  • Lack of recognition of depressive symptoms by patient and family (seen as part of getting old)


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  • When evaluating the elderly depressed patient, we need to: (Cont.)

    • Identify any prior psychiatric illness

    • Identify comorbid illnesses

    • Baseline medical history

    • Overall cognitive capacity

    • Identify current stressors

    • Evaluate medication that might contribute to depression

    • Receive objective information from family/caregiver


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Different Presentation of Depression (Cont.)

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

  • Mask depression (somatic complaints, anxiety)

  • Subsyndromal presentation (minor symptoms, dysthymia)

  • Depression due to medical condition

  • Vascular depression


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Diagnosis (Cont.)

  • MDD

    • Criteria for Depression DSM IV-TR

      • 2 week period with 5 or more of the following with 1 being either depressed mood or loss of interest/pleasure

        • Depressed mood most of the day/every day (subjective or objective)

        • Diminished interest/pleasure – anhedonia

        • Weight loss or gain >5% in a month or change in appetite

        • Insomnia or hypersomnia nearly every day

        • Psychomotor retardation or agitation (objective)

        • Loss of energy nearly every day

        • Worthlessness or guilt nearly every day

        • Decreased concentration

        • Suicidality/passive death wish

      • Symptoms cause clinically significant distress or impairment

      • Symptoms are not better accounted for by another psych illness

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


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Minor Depression (Cont.)

  • Subsyndromal presentation

  • It is now introduced as a DSM IV category

  • Much more seen in community samples

  • It is considered to represent a spectrum:

    • Prodromal/residual symptoms of MDE

    • Occurs in patients with underlying medical condition and dementing processes

    • The consequences on functional capacity are substantial


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Proposed Diagnostic Criteria (Cont.)

  • 1) Presence of low mood and/or loss of interest in all activities most of

    the day, nearly every day, and

  • 2) At least two additional symptoms from the DSM checklist:

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

    • Insomnia or hypersomnia nearly every day

    • Psychomotor retardation or agitation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)

    • Fatigue or loss of energy nearly every day

    • Feelings of worthlessness or excessive or inappropriate guilt) which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)

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

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


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Proposed Diagnostic Criteria (Cont.) (Cont.)

  • The symptoms cause clinically significant distress or impairment in social and occupational functioning

  • 17 item Hamilton Rating Scale for Depression (Ham-D) score of >10, or Geriatric Depression Scale Score of >12

  • Duration of at least 1 month

    Duration subtypes:

    a. Duration from 1-6 months

    b. Duration from 6-24 months

    c. Duration >24 months


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Proposed Diagnostic Criteria (Cont.) (Cont.)

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

  • Organic criteria:

    - objective evidence from physical and neurological examination and laboratory tests; and/or history of cerebral disease, damage, or dysfunction, or of systemic physical disorder known to cause cerebral dysfunction; including hormonal disturbances and drug effects

    - a presumed relationship between the development or exacerbation of the underlying disease and clinically significant depression

    - the disturbance occurs exclusively to the direct psychological effect of alcohol or a substance use

    - recovery or significant improvement of the depressive symptoms following removal or improvement of the underlying presumed cause


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Proposed Diagnostic Criteria (Cont.) (Cont.)

8) Exclusion criteria:

There has never been:

an episode or mania or hypomania;

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


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Depression and Medical Illness (Cont.)

  • Medical illness greatly increases riskf or depression

  • Risk to particularly high in

    • Ischemic heart disease (e.g., MI, CABG)

    • Stroke

    • Cancer

    • Chronic lung disease

    • Arthritis

    • Alzheimer’s disease

    • Parkinson’s disease

  • Mechanisms of depression vary

  • Medical Illness may confuse the diagnosis of depression in medical patients


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Depression Due to Medical Condition (Cont.)

  • Older age of onset

  • Organic features on MSE

  • Lower incidence of family hx of depression

  • Less likely to have SI/HI

  • More likely to improve at discharge

  • Higher morbidity and mortality in CAD, MI and CVA

  • Atypical presentation


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Medications Associated With (Cont.)Depression and Anxiety

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.


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Drugs Linked to Depression/Anxiety (Cont.)

  • Beta-blockers

  • Other antihypertensives

  • Reserpine

  • Digoxia

  • L-Dopa

  • Steroids

  • Benzodiazepines

  • Phenobarbital

  • Neuroleptics


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“Masked” Depression (Cont.)

  • Terminal insomnia, often with ruminations

  • Decreased appetite and weight loss

  • Extreme fatigue vs. anxiousness, restlessness

  • Increased, frequently delusional, preoccupation with bodily functions, pain and weakness

  • Expression of fears and anxiety without reason

  • Low self-esteem or self-concept

  • Increased isolation, loss of interest and pleasure

  • Hopelessness, suicidal ideation

    • All in context of “not feeling well physically”

    • Depression is felt to be “secondary”


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Clues to Depression in Primary Care (Cont.)

  • Help-seeking, persistent complaints

Pain GI Symptoms

Arthritis Multiple diffuse symptoms

Weight Loss Headache

Insomnia

  • Frequent calls and visits

  • High utilization of services

  • Treatment refusal, non-compliance


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Additional Clues in Nursing Home (Cont.)

  • Apathy, withdrawal, isolation

  • Failure to thrive

  • Agitation

  • Delayed rehabilitation


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Additional Clues in Hospitalized Patients (Cont.)

  • CABG, hip fracture, MI, stroke, arthritis

  • Delayed recovery

  • Treatment refusal

  • Discharge problem


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Chronic Pain and Depression (Cont.)

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

  • 12% in patients with 3 or more such complaints


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Depression and Neurodegenerative Brain Disease (Cont.)

  • Alzheimer’s Dementia

  • Vascular Dementia/Cerebrovascular Disease

    • Apathy

    • Nondysphoric Depression

  • Parkinson’s Disease


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Vascular Depression (Cont.)

Cerebrovascular disease can:

- predispose

- precipitate

- perpetuate

- a depressive syndrome


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Risk Factors of Vascular Depression (Cont.)

  • Male gender

  • Older age

  • Diabetes Mellitus

  • Smoking


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

  • Atrial fibrillation

  • Left Ventricular Hypertrophy

  • Higher systolic blood pressure

  • Angina Pectoris

  • Congestive Heart Failure


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Cerebrovascular Evidence in Late Life Depression (Cont.)

  • Genetic and early life stressors less important

  • Diffuse brain dysfunction

  • Cortical atrophy

  • Diffuse hypometabolism


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

  • Deep white and gray matter hyperintensities on MRI

  • Small vessel disease postmortem

  • Relation between stroke and depression


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Localization of Brain Disease (Cont.)in Depression

  • Hyperintensities in:

    - left hemisphere deep white matter

    - left putamen


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Localization of Brain Disease (Cont.) in Depression (Cont.)

  • Lesions of:

  • - caudate

  • - frontal lobe

  • - basal ganglia


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Brain Function Evidence (Cont.)

  • Hypoactivity of the caudate and frontal regions including

    - dorsolateral frontal region

    - inferior orbitofrontal region

    - medial anterior cingulate


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Summary of Vascular Mechanisms of Late-Life Depression (Cont.)

  • Small lesions disrupt critical pathways:

    - frontostriatal, circuitry and limbic

    hippocampal connections

    - damage of the catecholamine neurons by

    white matter lesions in the pons

    - Disruption of the orbital frontal cortex control

    over the serotonergic raphe nuclei


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Symptoms and Presentation (Cont.)

  • Increased psychomotor retardation

  • More prominent cognitive impairment

  • Poor performance on neuropsychological tests


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Symptoms and Presentation (Cont.) (Cont.)

  • Less agitation and guilt

  • Increased disability

  • Older age of onset

  • Executive dysfunction and apathy


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Two Major Behavioral Symptoms in Late-Life (Cont.)

- Apathy

- Executive Function


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Apathy (Cont.)

A state of reduced motivation.


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Types of Apathy (Cont.)

  • Motor apathy

    - Tendency not to initiate motor activity

  • Motivational apathy

    - Absence of motivation to initiate new activities

  • Emotional apathy

    - Absence or reduction of emotional interest

  • Cognitive apathy

    - Absence of generative ideation


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Conditions Associated with Syndrome of Apathy (Cont.)

  • Alzheimer’s Disease

  • Vascular Disease

  • Brain Damage

  • Partially treated depression

  • Psychotic depression

  • Schizophrenia

  • Drug-induced (neuroleptics, SSRI’s, marijuana, amphetamine or cocaine withdrawal)

  • Other: apathetic hyperthyroidism, lyme dz, chronic fatigue, testosterone deficiency, sleep apnea, etc.


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Executive Dysfunction (Cont.)

  • Decreased:

  • attention

  • initiation

  • organization

  • planning

  • abstract thinking


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Screening for Depression (Cont.)

  • Evidence-based literature is somewhat sparse and at times conflicting

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


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Overview of Currently Used Depression Scales in Geriatric Patients

  • When using screening instruments in elderly patients it is important to consider the cognitive level

    • Visual auditory deficits

    • Function level

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


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Geriatric Depression Scale (GDS) Patients

  • 30 questions that indicate presence of depression

  • Yes/No format

  • Might be more appropriate for elderly patients

  • Sensitivity 92%

  • Specificity 89%

  • Valid measure of depression in elderly patients

  • Validity decreases in nursing home patients and appears to be dependent on the degree of cognitive impairment

  • Can be used in inpatient and outpatient

  • Very reliable for phone screening

  • Available for minorities


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

  • Best validated scale for patients with dementia

  • Use information from both patients and outside informant

  • Better validated for patients with mild and moderate dementia than with severe form

  • Could depict depression in patients with Alzheimer's.


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Montgomery/Asperg Depression Rating Scale (MADRS) Depression in Dementia or CSDD)

  • Observer rated assessment

  • Based on clinical interview

  • Does not assess somatic symptoms that are important in geriatric population

  • Not very well validated in geriatric patients


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Zung Self-Rating Depression Scale Depression in Dementia or CSDD)

  • Self assessment scale

  • Uses graded answers (never, sometimes, always, usually which might be problematic for geriatric patients)

  • High false positive results in normal elderly

  • High false negative results if patients has somantic problems62


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Beck Depression Inventory (BDI) Depression in Dementia or CSDD)

  • Developed by Beck, Steer & Brown

  • Assesses the intensity of depressive symptoms

  • 5-10 minutes to administer

  • Highly reliable regardless of the population tested

  • Available in Spanish


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Hamilton Rating Scale for Depression Depression in Dementia or CSDD)

  • Goal standard of observer-rated depression scale

  • Requires training to complete

  • Takes 20-25 minutes to administer

  • Valid for all ages

  • Can be used in both clinical and research

  • Assesses the severity of depression


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Screening Measures for Depression in Children, Depression in Dementia or CSDD)

Adolescents, Adults, and the Elderly

Measure Spanish VersionNo of Items Time to CompletePsychometric properties/cutoff


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Medications Useful in Treating Depression Depression in Dementia or CSDD)

Medication Doses Ranger Uses Precautions


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Psychosocial Interventions for Depression Depression in Dementia or CSDD)

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

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

  • Family counseling

  • Substance abuse interventions as indicated

  • Bereavement counseling and services as needed

  • Health promotion and maintenance: good nutrition, light physical exercise, attention to chronic medical conditions, establish a regular daily routine


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Conclusion Depression in Dementia or CSDD)

  • When diagnosing depression in geriatric patients, there are 5 essential objectives:

    • Determine etiology and diagnosis

    • Provide disease specific management

    • Manage behaviors and target symptoms (symptoms that are the most distressing)

    • Prevent secondary complications (side effects of medication)

    • Rule out dementing process/medical illness

    • Support the families


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