Alina Rais, M.D. Associate Professor of Psychiatry Medical Director Geriatric Psychiatry Center

1. 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

2. 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

3. US Population: age 65 and over

4. 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

5. 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

6. One of the most common mental illnesses in the elderly is Depression Syndrome which includes the following symptoms: Physical Emotional Cognitive

7. 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

8. The NIH Consensus (Cont.) Depression: • Increases morbidity and mortality • It is a recurrent illness • Occurs more frequently in nursing homes

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

10. 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

11. 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.

12. 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.

13. 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.

14. 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

15. 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

16. Physical Disability Depression

17. 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

18. 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

19. Psychological Risk Factors • Decreased social support • Decreased functionality • Placement in a nursing home • Life events, i.e. retirement

20. Psychological Risk Factors (Cont.) • Changes in financial status • Bereavement • History of mental illness • Decreased self-esteem

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

22. 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)

23. 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

24. 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

25. 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

26. 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

27. Proposed Diagnostic Criteria • 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

28. Proposed Diagnostic Criteria (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

29. Proposed Diagnostic Criteria (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

30. 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.

31. 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

32. 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

33. Medications Associated With 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.

34. Drugs Linked to Depression/Anxiety • Beta-blockers • Other antihypertensives • Reserpine • Digoxia • L-Dopa • Steroids • Benzodiazepines • Phenobarbital • Neuroleptics

35. “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”

36. Clues to Depression in Primary Care • 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

37. Additional Clues in Nursing Home • Apathy, withdrawal, isolation • Failure to thrive • Agitation • Delayed rehabilitation

38. Additional Clues in Hospitalized Patients • CABG, hip fracture, MI, stroke, arthritis • Delayed recovery • Treatment refusal • Discharge problem

39. 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

40. Depression and Neurodegenerative Brain Disease • Alzheimer’s Dementia • Vascular Dementia/Cerebrovascular Disease • Apathy • Nondysphoric Depression • Parkinson’s Disease

41. Vascular Depression Cerebrovascular disease can: - predispose - precipitate - perpetuate - a depressive syndrome

42. Risk Factors of Vascular Depression • Male gender • Older age • Diabetes Mellitus • Smoking

43. Risk Factors of Vascular Depression (Cont.) • Atrial fibrillation • Left Ventricular Hypertrophy • Higher systolic blood pressure • Angina Pectoris • Congestive Heart Failure

44. Cerebrovascular Evidence in Late Life Depression • Genetic and early life stressors less important • Diffuse brain dysfunction • Cortical atrophy • Diffuse hypometabolism

45. Cerebrovascular Evidence in Late Life Depression (Cont.) • Deep white and gray matter hyperintensities on MRI • Small vessel disease postmortem • Relation between stroke and depression

46. Localization of Brain Diseasein Depression • Hyperintensities in: - left hemisphere deep white matter - left putamen

47. Localization of Brain Disease in Depression (Cont.) • Lesions of: • - caudate • - frontal lobe • - basal ganglia

48. Brain Function Evidence • Hypoactivity of the caudate and frontal regions including - dorsolateral frontal region - inferior orbitofrontal region - medial anterior cingulate

49. 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

50. Symptoms and Presentation • Increased psychomotor retardation • More prominent cognitive impairment • Poor performance on neuropsychological tests