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  2050 – Projected increase of 22% in elderly population

US Population: age 65 and over

80 30 20 10 0 70 60 50 40 1900 1930 1960 1990 2025 2045 Millions

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

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

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

Physical Emotional Cognitive

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

The NIH Consensus (Cont.)

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

Suicide in the Elderly

 Elderly suicide up by 9% in the last decade  White males over 65 account for 81% of all suicides

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

70 Depression: Underrecognized and Undertreated in the Elderly 60 50 40 30 20 10 0 Depression Told Physician Counseling Medication ECT

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

Health Services Utilization in Depressed Elderly Patients

20 15 10 5 0 Depressed Not Depressed Visits Laboratory Tests Radiological Procedures Consultations Total

*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.

Rates of Completed Suicide

80 70 60 50 40 30 20 10 0 10 14 20 24 30 34 40 44 50 54 60 64 70 74 80 84 Total Male Females

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.

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

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

Depression External/Underlying factors (examples): Preclinical dementia Poverty Low social support Medical illness Increased Risk for Incident Physical Illness Vascular disease (stroke, coronary artery disease) Cancer?

Osteoporosis?

Hip fracture Health behaviors: Poor medication adherence Non-adherence to visual or hearing aids?

Smoking and physical inactivity Poor participation in rehabilitation Features of the depressed state: Executive-type cognitive deficits Poor appetite, causing low body mass index Psychomotor retardation Apathy and motivational deficit Sleep disturbance Decreased pain threshold Sequelae of disability: Increased negative life events Loss of perceived control Low self-esteem Social activity restriction Strained interpersonal relationships Physical Disability

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

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

Psychological Risk Factors

 Decreased social support  Decreased functionality  Placement in a nursing home  Life events, i.e. retirement

Psychological Risk Factors (Cont.)

 Changes in financial status  Bereavement  History of mental illness  Decreased self-esteem

 Diagnosing depression in the elderly could be challenging  Elderly population received 20-30% of all prescribed medications  Experience decline of cognitive and functional capacity

Barriers in Diagnosing Depression in Elderly Patients

     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)

 When evaluating the elderly depressed patient, we need to: – 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

Different Presentation of Depression

 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



Diagnosis

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

Minor Depression

    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

Proposed Diagnostic Criteria

  a.

b.

c.

d.

e.

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 f.

g.

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

Proposed Diagnostic Criteria (Cont.)

3) 4) 5) 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.

c.

Duration from 6-24 months Duration >24 months

Proposed Diagnostic Criteria (Cont.)

6) 7) 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

Proposed Diagnostic Criteria (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.

Depression and Medical Illness

    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

Depression Due to Medical Condition

       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

Anticancer Anticholinergic Anti-inflammatory/ anti-infective Cardiovascular Hormones Psychotropics Stimulants Sympathomimetics Withdrawal from:

Medications Associated With Depression and Anxiety

Cimetidine, cyclotherine, other, levodopa, ranitidine Amopine, benztropine, hycosamine, probanthine Baclofen, disulfirma, ethambutol, fenoprofen, indomethacin, naproxen, phenylbutazone, sulfonamides Bethanidine, clonidine, diuretics, guanethidine, hydralazine, methyldopa, propranolol, reserpine, thiazide Anabolic steroids, corticotrophin, estrogen hormone blocker, glucocorticoids, oral contraceptives Benzodiazepines, neuroleptics Caffeine, nicotine Appetite suppressants, ephedrine, pseudoephedrine Alcohol, amphetamines, cocaine, hypnotics, sedatives a d d

Drugs Linked to Depression/Anxiety

         Beta-blockers Other antihypertensives Reserpine Digoxia L-Dopa Steroids Benzodiazepines Phenobarbital Neuroleptics

“Masked” Depression

        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”

Clues to Depression in Primary Care

 Help-seeking, persistent complaints Pain Arthritis Weight Loss Insomnia GI Symptoms Multiple diffuse symptoms Headache • Frequent calls and visits • High utilization of services •Treatment refusal, non-compliance

Additional Clues in Nursing Home

 Apathy, withdrawal, isolation  Failure to thrive  Agitation  Delayed rehabilitation

Additional Clues in Hospitalized Patients

 CABG, hip fracture, MI, stroke, arthritis  Delayed recovery  Treatment refusal  Discharge problem

Chronic Pain and Depression

 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

Depression and Neurodegenerative Brain Disease

 Alzheimer’s Dementia   Vascular Dementia/Cerebrovascular Disease – Apathy – Nondysphoric Depression Parkinson’s Disease

Vascular Depression

Cerebrovascular disease can: - predispose - precipitate - perpetuate - a depressive syndrome

Risk Factors of Vascular Depression

 Male gender  Older age  Diabetes Mellitus  Smoking

Risk Factors of Vascular Depression (Cont.)

 Atrial fibrillation  Left Ventricular Hypertrophy  Higher systolic blood pressure  Angina Pectoris  Congestive Heart Failure

Cerebrovascular Evidence in Late Life Depression

 Genetic and early life stressors less important  Diffuse brain dysfunction  Cortical atrophy  Diffuse hypometabolism

Cerebrovascular Evidence in Late Life Depression (Cont.)

 Deep white and gray matter hyperintensities on MRI  Small vessel disease postmortem  Relation between stroke and depression

Localization of Brain Disease in Depression

 Hyperintensities in: - left hemisphere deep white matter - left putamen

Localization of Brain Disease in Depression (Cont.)

• Lesions of: - caudate - frontal lobe - basal ganglia

Brain Function Evidence

 Hypoactivity of the caudate and frontal regions including - dorsolateral frontal region - inferior orbitofrontal region - medial anterior cingulate

Summary of Vascular Mechanisms of Late-Life Depression

 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

Symptoms and Presentation

 Increased psychomotor retardation  More prominent cognitive impairment  Poor performance on neuropsychological tests

Symptoms and Presentation (Cont.)

 Less agitation and guilt  Increased disability  Older age of onset  Executive dysfunction and apathy

Two Major Behavioral Symptoms in Late-Life

- Apathy - Executive Function

Apathy A state of reduced motivation.

Types of Apathy

    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

Conditions Associated with Syndrome of Apathy

        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.

Executive Dysfunction

Decreased: • attention • initiation • organization • planning • abstract thinking

Screening for Depression

 Evidence-based literature is somewhat sparse and at times conflicting  Majority of physicians would rely on individual judgment when assessing depression in the elderly

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

Geriatric Depression Scale (GDS)

          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

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.

Montgomery/Asperg Depression Rating Scale (MADRS)

 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

Zung Self-Rating Depression Scale

 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

Beck Depression Inventory (BDI)

 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

Hamilton Rating Scale for Depression

 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

Measure ELDERLY

Beck Depression Inventory (BDI) Screening Measures for Depression in Children, Adolescents, Adults, and the Elderly

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

Yes 21 5 to 10 Alpha: 0.76/above 15 Center for Epidemiological Studies Depression Scale (CES-D) Cornell Scale for Depression in Dementia Yes NO Geriatric Depression Scale (GDS) Yes Geriatric Depression Scale short Zung Depression Rating Scale Yes No 20 19 30 15 20 5 to 10 Sensitivity: 92% Specificity: 87%/above 15 10 with patient, 20 with caregiver Sensitivity: 90% Specificity: 75%/above 12 10 to 15 5 to 10 5 to 10 Specificity: 100%/above 13 Sensitivity: 92% to 97% Specificity: 64.8% to 81%/above 5 Specificity: 63%/above 49

Medications Useful in Treating Depression Medication Doses Ranger Uses Precautions

Psychosocial Interventions for Depression

      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

Conclusion

 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