CHAMP Depression in the Hospitalized Older Patient

1. CHAMPDepression in the Hospitalized Older Patient Joanna Martin, MD Horizon Hospice and Palliative Care, Chicago Mariko K Wong, MD University of Chicago

2. Topics for discussion • Why should we screen inpatients for depression and who is at risk? • Depression in the elderly can present atypically • Review screening tools • Discuss pharmacotherapy • Planning for continuity after discharge

3. Prevalence of Depression • Community • 2% major, 10-30% depressive symptoms • Outpatient Setting • 5-10%, 10-30% • Inpatient Setting • 10-20%, 10-30% • Long-term care setting • 10%, 30%

4. Clinical Case One • 80 year old female with DM, Htn, and OA, admitted from ER with insomnia, headaches and weight loss (>5% of body weight). • PMH: DM, htn, history of “anxiety” • Meds: HCTZ, metoprolol, metformin, Lorazepam prn • SH: lives alone, has a daughter that checks in on her • Exam: anxious, otherwise normal exam

5. Isn’t depression an outpatient issue? Many older patients with depression are “missed” in the outpatient setting • Up to one-half of all depressed elderly seen by primary care physicians are not identified as depressed • In one study, 40% of depressed elderly patients attributed depression to “old age” and were much less likely to discuss with their doctor1

6. Why screen in the hospital? Depressive symptoms in older, hospitalized patients increase risk for: • Mortality • Rehospitalization • Functional Decline

7. Association with Mortality • 3 year mortality is higher with ≥6 depressive symptoms • (56% vs. 40%, hazard ratio = 1.56 [95% CI, 1.22-2]; p=0.001) After adjustment for cofounders, hazard ratio = 1.34 [CI, 1.03-1.73] Covinsky et al. Ann Intern Med. 1999

8. Association with Hospital Readmission Depressive symptoms are associated with an increased rate of hospital readmission (adjusted hazard ratio, 1.50; 95% CI 1.03-2.17; p=.03) Bula, C. J. et al. Arch Intern Med 2001;161:2609-2615.

9. Association with Functional Decline • Patients with ≥6 depressive symptoms & dependent in ≥1 ADL were more likely to have functional decline: • At discharge (OR 3.23 CI 1.76-5.96) • At 30d (OR 3.45 CI 1.81-6.60) • At 90d (OR 2.15 CI 1.15-4.030 Covinsky, K. E. et. al. Ann Intern Med 1997;126:417-425

10. Depression in the Hospitalized Patient – Why screen? • Can increase length of hospital stay because slows recovery and mobilization • Inpatient setting is a good time to make a diagnosis and get referrals in place • Treatments are effective! Crystal et al. JAGS 51(1718-1728, 2003

11. Risk of Recurrence • Depression should be viewed as a chronic illness, making identification even more important • Recent randomized, double blind study showed high risk of recurrence in older patients (NEJM 354;11) • Patients treated with SSRI were less likely to have recurrent depression • Relative risk of recurrence among patients receiving placebo: 2.4 (95% CI 1.4 - 4.2) • Number needed to treat to prevent one recurrence: 4 (95% CI 2.3 - 10.9) Reynolds et al. NEJM 2006;354:1130-8

12. Back to our clinical case • Husband passed away one year ago • Daughter reports the onset of wt loss, insomnia and headaches at that time • She thought her mother might be “down” about her father’s death but thought her mom’s level of grief was appropriate and typical of her getting older

13. Female gender (gap narrows with increasing age) Divorced or separated status Low socioeconomic status Poor social supports Comorbid illness Cognitive Impairment Adverse/Stressful life events Family history Prior depressive episodes Prior suicide attempts Financial Stress Who is at Risk?

14. History of CVA Cancer MI Rheumatoid Arthritis COPD Parkinson’s Disease Diabetes Mellitus Dementia Hip fracture / fall Associated Medical Problems

15. Clinical Case Two • 80 year old male with history of a stroke one year ago, DM, Htn, admitted through ER for mental status changes; patient’s son concerned about increased confusion • SH: lives alone in assisted living, son sees once a week • Exam: VSS, alert and interactive, some short term memory loss notable (MMSE 23/30), low vision, stable mild right-sided weakness from old stroke

16. Post-CVA Depression • >30% of stroke victims • Risk highest in first two years after a stroke • Within 10 years after a stroke, the risk of death is 3.5 times higher in depressed patients* *Am J Psychiatry 1993 Jan;150(1):124-9

17. Diabetes • Higher risk of developing depression • Diabetic patients often have more comorbid health problems i.e. painful peripheral neuropathy, heart disease, vision loss etc. • Consider routine screening

18. Alzheimer’s Disease • Depression occurs in up to 50% of patients and can cause cognitive deficits • In the early stages, 10% of patients develop MDD; 30% develop symptoms of minor depression • In severe dementia, 12% with MDD but probably an underestimate

19. Pseudodementia • Situation where patients seem demented but are actually depressed • Patients who appear to demonstrate complete cognitive recovery with antidepressant treatment • Develop high rates of dementia (20% per year)

20. Atypical presentation • Older depressed patient often has different complaints and presentation than younger patients • Less commonly experience “mood symptoms” • Older patients often have more somatic symptoms and may end up hospitalized Stewart. PGM. 2004;115(6)

21. Depression in older adults: what else to look for? • Irritability, anxiety or decreased functional capacity (in a hospital setting, this can confuse physicians and may prolong length of stay) • Recognize that the role of coexisting medical problems, cognitive deficits, and multiple medications complicates the picture • Many assume depression is a normal response to aging

22. Bereavement • Older patients are more likely to experience significant losses • Major depression should always be treated as a serious illness even if precipitated by life circumstances • Antidepressants have shown to benefit patients with bereavement-related depression

23. Who should be screened? • Patients with commonly associated medical conditions • Adverse life events • Physical signs and symptoms: pain, insomnia, weight loss, fatigue • Even if they do not complain of “feeling depressed”!

24. Geriatric Depression Scale: Short Form • 1. Are you basically satisfied with your life? • 2. Have you dropped many of your activities and interests? • 3. Do you feel that your life is empty? 4. Do you often get bored? • 5. Are you in good spirits most of the time? • 6. Are you afraid that something bad is going to happen to you? • 7. Do you feel happy most of the time? • 8. Do you often feel helpless? • 9. Do you prefer to stay at home, rather than going out and doing new things? • 10. Do you feel you have more problems with memory than most? • 11. Do you think it is wonderful to be alive now? • 12. Do you feel pretty worthless the way you are now? • 13. Do you feel full of energy? • 14. Do you feel that your situation is hopeless? • 15. Do you think that most people are better off than you are? Sheikh et al. J Psychiatric Res 1983;17:37-49

25. More about GDS • Probably the most widely accepted in older patients • Takes about 5 minutes to complete, yes or no answers (simple) • 92% sensitivity and 89% specificity, performs well in inpatient settings • Cons: Does not ask about sleep, somatic symptoms, or suicidal ideation. Not validated for treatment response. • Website with references, versions in multiple languages, and apps for iphone/android: • http://www.stanford.edu/~yesavage/GDS.html

26. 9-Item Patient Health Questionnaire (PHQ-9)

27. More abut PHQ-9 • Not as well-validated as GDS in older patients • Sensitivity and specificity of 88% • Does ask about suicidality, and has been validated to assess for treatment response • Cons: More complex for patients to answer, especially those with cognitive impairment

28. Screening Tools: Teaching Point • Great opportunity to involve the medical students in plan of care • Can distribute GDS and encourage students to screen elderly patients at risk

29. Medications Associated • Antihypertensives agents are a cause of depressive symptoms in the geriatric population -B-blockers (Atenolol has less of a CNS effect) -Clonidine • Antiparkinson’s meds (levodopa class) often cause depression as can Parkinson’s disease itself. • Others: benzos, propranolol, barbiturates, antihistamines

30. Treatment: Medications • SSRIs are somewhat interchangeable regarding effectiveness • Choose an SSRI based on its side effect profile, drug interactions and compliance • Citalopram and sertraline are often recommended among experts for efficacy and tolerability in the elderly • Paroxetine: anticholinergic properties and short half-life making withdrawal more common when patients miss doses • Newer antidepressants • Bupropion: usually activating • Mirtazapine: can increase appetite and improve sleep • Duloxetine: improves pain

31. Treatment: Non-pharm • Cognitive behavioral therapy and interpersonal therapy can be helpful • In the outpatient setting, RCT of pharmacotherapy and brief psychotherapy shown to be more effective than usual care • Emerging data showing physical activity and exercise can be helpful Unützer et al. JAMA. 288(22)

32. Other Treatments • Ritalin – can be used short term • ECT- may be treatment of choice in patients with refractory, severe depression or depression with psychosis

33. Clinical Case One • 80 year old female with htn, osteoarthritis, admitted from ER with insomnia, headaches and some mild weight loss. • PMH: Htn, history of “anxiety” • Meds: HCTZ, Lopressor, Lorazepam prn • SH: lives alone, has a daughter that checks in on her • Exam: anxious, otherwise normal exam

34. Clinical Case One • More information: patient had lost her husband one year ago • Daughter had noticed decline every since her father had died but thought it was just “old age” • Had missed several appointment with her outpatient PCP • Screens positive on GDS with score of 8/15

35. Treatment Plan • Social Work referral made to DOA • Plan made to wean patient off of lorazepam and changed BP med • SSRI started in the hospital • Patient’s PCP made aware of treatment plan with follow up soon after hospitalization • Referral to outpatient psychiatry and support group; daughter agreed to make sure her mother got to appointments

36. Clinical Case Two • 80 year old male with history of a stroke one year ago, DM, Htn, admitted through ER for mental status changes; patient’s son concerned about increased confusion • SH: lives alone in assisted living, son sees once a week • Exam: VSS, alert and interactive, low vision, some short term memory loss notable (MMSE 23/30), stable mild right-sided weakness from old stroke

37. Back to clinical case two • The patient was medically stable and not delirious • The patient screened positive (GDS 10/15) • ? depressive symptoms contributed to cognitive deficits • Patient’s son educated about situation • Patient started on antidepressant • Outpatient follow-up

38. Teaching points for the wards • Identify misconception that depression is only an outpatient issue • Depression in the hospital is associated with increased mortality, rehospitalization, and functional decline • Depression often has different presentation in the elderly – keep on the differential

39. In summary . . . • Screen for depression in geriatric inpatients at risk • Recognize atypical presentations in the elderly • Review medications • Initiate a treatment plan in house and arrange for appropriate follow-up

40. Bibliography: Page One • Arean PA Ayalon L. Assessment and Treatment of Depressed Older Adults in Primary Care. Clinical Psychology: Science and Practice 2005 12(3):321-335. • Blake H, et al. How Effective are Physical Activity Interventions For Alleviating Depressive Symptoms in Older People? A Systematic Review. ClinRehabil. 2009;23:837-87 • Bula CJ et al. Depressive Symptoms as a Predictor of 6-Month Outcomes and Services Utilization in Elderly Medical Inpatients. Archives of Internal Medicine. 2001;161:2609-2615. • Covinsky KE et al. Depressive Symptoms and 3-Year Mortality in Older Hospitalized Medical Patients. Annals of Internal Medicine 1999 130(7):563-569. • Covinsky KE et al. Relation between Symptoms of Depression and Health Status Outcomes in Acutely Ill Hospitalized Older Persons. Annals of Internal Medicine. 1997. 126(6):417-25. • Crystal S et al. Diagnosis and Treatment of Depression in the Elderly Medicare Population: Predictors, Disparities, and Trends 2003. 51(12):1718-1728. • Grossberg GT. Clinics in Geriatric Medicine: Geriatric Mental Health. 19(4). 2003 • Ham RJ et al. Primary Care Geriatrics: A Case-Based Approach. Fourth Edition. Mosby: 2002. 309-321. • Kroenke K et al. THE PHQ-2: Validity of a Two Item Depression Screener. Med Care. 2003 Nov;41(11):1284-92.

41. Bibliography: Page Two • Kroenke K et al. The PHQ-9: Validity of a Brief Depression Severity Measure. JGIM 2001. 16(9) p 606. • Morris PL et al. Association of depression with 10-year poststroke mortality.Am J Psychiatry 1993 Jan;150(1):124-9. • Raj A. Depression in the Elderly: Tailoring Medical Therapy to Their Special Needs. Postgraduate Medicine 2004 115(6). • Reynolds CF et al. Maintenance Treatment of Major Depression in Old Age. NEJM. 2006; 354:1130-8. • Sable JA et al. Late-life depression. How to Identify its Symptoms and Provide Effective Treatment. Geriatrics 2002 57(2). • Sarkisian CA et al. Do depressed older adults who attribute depression to “old age” believe it is important to seek care? J Gen Intern Med. 2003;18:1001-5. • Sheikh JI et al. Geriatric Depression Scale: recent evidence and development of a shorter version. Clinical Gerontology. 1986;5: 165-72. • Shua-Haim JR et al. Depression in the Hospitalized Elderly. Clinical Geriatrics 1998 6(4). • Stewart JT. Why don’t physicians consider depression in the elderly. Postgraduate Medicine. 2004; 115(6). • Unützer et al. Collaborative Care Management of Late-Life Depression in the Primary Care Setting. JAMA 288(22). 2836-2845. • Yesavage JA et al. Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatric Res 1983;17:37-49.