Post on 12-Jan-2016
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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