Depression
D
i in
i Older
Old Ad
Adults:
lt :
A Team Approach to
Assessment and Diagnosis
Rebecca Logsdon
Logsdon, PhD
UW School of NursingNursing-Psychosocial & Community Health
Northwest Research Group on Aging and Alzheimer’s Disease Research Center
Soo Borson, MD
UW School of Medicine – Psychiatry & Behavioral Sciences
Geriatric
G
r atr c and
an Family
Fam y Services
r c Clinic
n c and
an Alzheimer’s
z m r Disease
D a Research
arc Center
nt r
Assessment of Depression
Affective Symptoms
– Depressed mood
– Anxiety
A i t
Behavioral Symptoms
–
–
–
–
–
Sleep disturbance
pp
change
g
Appetite
Psychomotor change
Fatigue
S i l withdrawal
Social
i hd
l
Cognitive
g
Symptoms
y p
– Thoughts of death or
suicide
– Problems
P bl
concentrating
i
– Guilt feelings
– Hopelessness or feelings
of worthlessness
Assessment of Depression
• Clinical interview
• Self report symptom checklist
• Behavioral observations
Assessment of Depression
Clinical Interview:
– patient and informant (if possible)
– unstructured
d (may
(
be unreliable)
l l )
– structured (better reliability)
• DSM symptom review – can be done by Patient
Health Questionnaire for Depression (PHQ(PHQ-9)
• Hamilton Depression Rating ScaleScale-17 items
items, rated
by severity, range 0
0--52
Assessment of Depression
Self report
p
symptom
y p
checklists:
Beck Depression Inventory (Beck et al., 1961)
21 items, rated on scale of increasing severity
Requires significant reading and detailed response choices
Center for Epidemiologic StudiesStudies-Depression (Radloff, 1977)
20 items,
items rated on frequency in past week
Multiple choice, less reading
Geriatric Depression Scale (Yesavage et al.,
al 1983)
30 items, rated on current symptoms; 55- and 1515-item versions also good
Designed specifically for older adults
Yes/no format; can be used with people with mild to moderate
dementia
Assessment of Depression
Behavioral Observation:
Observation of affect and comments during interview, reports
from family member
Pleasant Events Schedule
Schedule--Elderly (Teri & Lewinsohn, 1982)
144 items, rated on frequency and enjoyment
May be used as a therapeutic tool for people who have decreased
activity due to depression or illness
Di
Diary
or daily
d il llog tto document
d
t activities,
ti iti
th
thoughts
ht and
d affect
ff t
Structured or unstructured, e.g. daily mood rating versus open ended
journaling
Can
C include
i l d information
i f
ti about
b t sleep,
l
d
daily
il activity
ti it schedule,
h d l meals,
l and
d
social activities
Di
Diagnosis
i of
f D
Depression
i
• Popular understanding of depression
differs from clinical diagnosis
g
• Clinicians use specific diagnostic criteria
to identify subtypes
– Can help with treatment choice
Diagnosis of Major Depression
Consistently depressed mood
-OR
ORDi i i h d iinterest
Diminished
t
t or pleasure
l
in most activities
Diagnosis of Major Depression
At least 4 additional symptoms:
•weight/appetite change
•sleep
l
disturbance
di t b
•psychomotor agitation or slowing
•fatigue or loss of energy
•irrational guilt, feelings of worthlessness
•diminished ability to concentrate
•recurrent thoughts of death or suicide
Diagnosis of Major Depression
Impaired
mp
everyday
y y functioning
f
g
-ANDANDy p
present
p
for at least 2 weeks
Symptoms
-OR
ORp
still present
p
more
Symptoms
than 2 months after
bereavement
D
Diagnosis
of
f Depressive
D
Symptoms
• Do not meet the criteria for a major
depression diagnosis
-BUTCan last a long time (even years)
Impair quality of life
Can affect health and behavior
-ANDND
Undermine relationships
Complications
p
of Depression
p
Diagnosis in Older Adults
Using DSM criteria, major depression decreases with
advancing age (5% in individuals over 65)
-BUT
BUTDepressive symptoms increase with advancing age
(17--30% in primary care patients over 65)
(17
Special
p
Considerations
in Older Adults
Older adults less likely to report dysphoria
– sadness
– unhappiness
– irritability
Older adults more likely to report physical symptoms
– g
generalized fatigue
g
– aches and pains
– amplified
p
symptoms
y p
of medical condition
Special
p
Considerations
in Older Adults
Symptoms occur in a complex medical and psychosocial context
Symptoms
y p
can overlap
p with other conditions
Patients, families and health care providers may attribute
symptoms to “normal aging” or “just slowing down”
Providers may be concerned about stigmatizing or upsetting
patients
Health care practice imposes restrictions –short appointments
force mental health concerns to compete with medical
symptoms and conditions for provider
provider’ss attention.
attention
Prevalence of Depression in
P
Primary
Care
40
35
30
25
20
15
10
5
on
Lo
nd
Ita
ly
e
Se
at
tl
re
H
am
ps
hi
N
ew
In
di
a
na
0
Depression in Older Adults
Epidemiologic Survey (1984)
• 15% community residents over 65 had significant
depressive symptoms
• 10% of those had received treatment
Health & Retirement Study (1998)
• Age 6565-79 – 15% significant depression
(women > men)
80+ - 23% significant depression
• Age 80
(women = men)
Treatment of Depression
p
in
Primary Care
Unützer
U
üt
ett al,
l 2003
18 clinics in 5 states, 1,801 patients 60 and older who met
criteria for Major Depression or Dysthymia
Treatment in past 3 months:
–No treatment
treatment: 6
64%
–Inadequate treatment: 17%
–Adequate treatment: 29%
Severity of symptoms was not
associated with rate of treatment
Adequate
Treatment
Inadequate
Treatment
No
Treatment
Depression
p
Treatment in
Primary Care
Gallo et al, 1997
Boston ECA Sample,
p 13 year
y
followup
p
Older adults with depressive symptoms at baseline
were at increased risk for subsequent:
–
–
–
–
functional impairment
cognitive impairment
psychological distress
death
Suicide in Older Adults
Individuals over age 85 have highest suicide rates of
any age group (CDC,
(CDC 1999)
– Individuals over age 85
– General population
21/100,000
11/100,000
11/100 000
– White men over age 85
65/100,000
Suicide
S i id completers
l t
(Caine
(C i et al,
l 1996,
1996 n=97)
97)
–
–
–
–
53% visited primary care MD in prior month
88% complained
mpl in d of
f ps
psychiatric
hi t i ssymptoms
mpt ms
42% treated for depression
10% received adequate treatment (correct med & dose)
Depression and Mortality
• Nursing Home Residents
– Increased risk of death by 59%
independent of physical health (Rovner,
1993)
• Heart Attack Patients (Myocardial
Infarction)
– Risk of mortality 5 times greater
(Frasure-Smith,
(F
m , 1995)
99 )
• Cancer Patients
– Increased cancer risk by 88% (Penninx,
1998)
• Random Sample of General Population
– No increased mortality (7.5 years), when
analysis adjusted for demographics,
demographics
baseline health, and functional status
(Everson-Rose, 2004)
Causes of Depression
Physical
y
Changes
g
P
Psychosocial
h
l Changes
h
Risk for Depression Increased
In…
•
•
•
•
•
•
•
•
•
Women,, esp
p Younger;
g
Men,, in Very
y Advanced Age
g
Previously Depressed
ecent y W
Widowed
dowed or Unmarried
nmarr ed
Recently
Stressful Life Events
Bereavement
Lack of Support Network
Nursing Home Residents
Serious and/or Chronic Illness
Caregivers
Causes of Depression
Physical Changes
– Circadian rhythm disruption
• persistent insomnia
– Brain diseases
– General medical illnesses
• especially
i ll associated
i
d with
i h
vascular damage
– Medications
Medical Illness & Depression
Noël et al (2004) n=1,801
n=1 801
Subjects all diagnosed with depression, and had
an average of 3
3.8
8 comorbid chronic illnesses
Depression was strongly associated with worse
physical and mental function, increased
disability, poorer self rated quality of life
Impact of depression was greater than the
impact
p
of medical comorbidities
Medical Illness & Depression
Cardiovascular (45%)
• congestive heart
failure
• myocardial infarction
Neurological (30(30-40%)
• dementia
• stroke
Parkinson’ss disease
• Parkinson
Endocrine (33%)
• diabetes
• thyroid disease
Musculoskeletal (25%)
• arthritis
• osteoporosis
• fractures
Other (45%)
•
•
•
•
chronic
h
i pain
i
lupus
multiple sclerosis
hospitalized
h
it li d with
ith
cancer
• COPD
(Teri et al, 1986; Rifkin, 1992; Mast, 1999; Kunik
et al, 2005)
Causes of Depression
Psychosocial Changes
– Losses: family, friends, pets
– Social isolation
Stress acute and chronic
– Stress,
– Helplessness, loss of control
– Too many unpleasant events
– Too few pleasant activities
Depression & Anxiety
Co--morbidity of depression and
Co
anxiety is a significant problem
Symptoms
ymp m of
f Anxiety
y
Excessive worrying, apprehension
Three or more of the following:
– Restlessness
n
or keyed
y up
– Easily fatigued
– Difficulty concentrating
– Irritability
– Muscle tension
– Sleep disturbance
AnxietyAnxiety
-Depression
Comorbidity in Adults
(N=255)
Social Phobia
Simple Phobia
Panic Disorder
GAD
OCD
Agoraphobia
h
27%
17%
15%
11%
6%
5%
%
Comorbidity
51%
No
Comorbidity
y
49%
Depression & Anxiety
Co-morbidity of depression and anxiety
Cosymptoms is a significant problem
– increased
incr s d sseverity
v rit of
fd
depression
pr ssi n
– increased likelihood of suicide attempts
– more iimpaired
i d social
i lf
functioning,
ti i
work,
k f
family
il
functioning
– less
l ss likely
lik l to
t respond
sp nd to
t singlesingle
sin l -modality
m d lit th
therapy
p
– more likely to drop out of treatment
Depression
Dementia
Diagnosing Depression
in Dementia
Expectations
Expectations
•“normal” to be depressed when you get a diagnosis
of dementia
Overlapping
r pp ng symptoms
ymp m
•cognitive change
•apathy / loss of interest
•sleep disturbance
•agitation / anxiety
Depression in Dementia
Affects both persons with dementia and family
caregivers
30% of
f patients
ti t with
ith d
dementia
ti h
have coco-morbid
bid
depression
70% of caregivers of depressed & demented family
members experience significant depressive symptoms
Depression increases behavioral and functional
impairment
Depression in Dementia
Video Clip:
p
Non--depressed
Non
Depression in Dementia
Video Clip:
p
Dementia Symptoms
Depression in Dementia
Video Clip:
p
Depressed
Depression in Dementia
Video Clip:
p
Depression Symptoms
Anxiety
Anxietynx ety-Depression
Depress on
CoCo
-morbidity in Dementia
(N 545)
(N=545)
Anxiety
y associated with
significantly greater
ADL impairment
Risk of behavior
problems four times
higher
hi h for
f anxious
i
patients
Comorbidity
53%
No
Comorbidity
47%
Depression in Dementia
Depression impacts quality of life in dementia more
th any other
than
th symptom
t
(more
(
than
th memory loss,
l
physical, and functional disability)
Both behavioral and pharmacological treatments are
effective
Identifying and treating depressive symptoms
improves functioning of the patient and decreases
burden for caregiver
Effective Depression
Treatment: Psychiatric and
Psychological Collaboration
Soo Borson MD
UW School of Medicine – Psychiatry & Behavioral Sciences
Geriatric and Family Services Clinic and Alzheimer’s
Disease Research Center
Rebecca Logsdon PhD
UW School of Nursing
Nursing-Psychosocial & Community Health
Northwest
N th
t Research
R
h Group
G
on Aging
A i and
d Alzheimer’s
Al h i
’
Disease Research Center
Treatment of Depression
Psychological Approaches:
Interpersonal Therapy
role transitions, interpersonal role disputes, relationship skill deficits,
grief
Cognitive Behavioral Therapy
address
dd
thoughts
th
ht and
d behaviors
b h i
th
thatt trigger
t i
and
d maintain
i t i symptoms
t
of
f
depression
Cognitive Behavioral Analysis System of Psychotherapy
developed specifically to treat chronic low
low-grade depression
Psychodynamic Therapy
life review and reminiscence
T
Treatment
t
t of
f Depression
D
i
Biological Approaches – No Medication
Bright Light Exposure
helps to reset circadian rhythms and decrease depressive
symptoms in Seasonal Affective Disorder
Exercise
can be as effective as other methods in physically healthy
persons
Experimental therapies
VNS,
VNS rTMS
rTMS, and DBS
Treatment of Depression
Pharmacologic
g Approaches
pp
: General Considerations
•Multiple drug classes and medications available
•Mechanisms of action complex
•All work equally well in clinical studies
•But individual differences in response and side effects
are important
T
Treatment
t
t of
f Depression
D
i
Pharmacologic Approaches: Geriatric Issues
• Sensitivity
y to some side effects (e.g.
g anticholinergic)
g
• Use of multiple medications for multiple conditions
• Slowing of drug metabolism – longer duration of action
• Physical vulnerabilities – poor balance, falls, confusion,
dry mouth, changes in bowel and bladder function
• Delayed
y response
p
• Undertreatment a bigger problem than overtreatment
T
Treatment
t
t of
f Depression
D
i
Pharmacologic Approaches: Specific Drugs
• Selective Serotonin Reuptake Inhibitors
– First line of drug therapy – usually safe, with relatively few side
effects
– Examples: sertraline
sertraline, citalopram
citalopram, fluoxetine,
fluoxetine paroxetine
• “Dual
“Dual--Action” Antidepressants
– Venlafaxine,
Venlafaxine mirtazapine
mirtazapine, duloxetine
• Antidepressant
Antidepressant--Antipsychotic Combination
– Fluoxetine + olanzapine in one pill
– Older combinations not generally used now
T
Treatment
t
t of
f Depression
D
i
• Tricyclic Antidepressants
– The original antidepressants
• Amitriptyline,
Amitriptyline nortripyline,
nortripyline imipramine,
imipramine desipramine
– Highly effective
– Difficult to use in older adults due to side effects
– Best used in low dose as part of chronic pain
management, not as antidepressant
• Other Antidepressant Medications
– Bupropion
– Trazodone (used mainly for sleep)
– MAOIs (only psychiatrists)
Treatment of Severe
Depression
• Electroconvulsive therapy
– Highly
H ghly effect
effective
ve in
n older adults
– Today’s methods are safe
life-threatening
threatening agitated
– Used selectively for life
or suicidal depression, and when drugs and
other methods fail
– Can be used when dementia is also present
g
and fear still prevalent
p
but unjustified
j
– Stigma
Treatment of Complicated
D
Depression
i with
i h Psychosis
P
h i or
Disabling Anxiety
• Combination Medications
– Antidepressant with antipsychotic
anti-anxiety
anxiety medications
– Antidepressant with anti
– Two antidepressants together
Treatment of Anxious
Components of Depression
• Added anxiolytic medications, esp. early on
• Focused psychotherapy
• Physical conditioning – building strength
and confidence
• Sleep hygiene
• Relaxation strategies
L
Learning
i R
Relaxation
l
ti St
Strategies
t i
• Progressive relaxation
• Deep
D
breathing
b
thi
• Guided imagery,
g y, meditation
• Gentle yoga
• Tai chi
Exercise especially walking
• Exercise,
Depression in Dementia
Treatment Options
Behavioral / Interpersonal
– Caregiver involvement essential
– Increase activity and pleasant events
– Problem Solving to identify and eliminate triggers of depressive
behaviors
Pharmacologic
– Medication monitoring essential
– Monitor effectiveness and side effects
– Patient may not accurately report treatment adherence, knowledgeable
and objective
j
informant necessary
y
Depression in Dementia
Changes in Hamilton Depression Scale
Pre to Post Behavioral Treatment
16
15
14
13
Pre
Post
12
11
10
BT-Pleasant
Events
BT-Problem
Solving
Nonspecific
Counseling
Wait List
Depression in Dementia
Clinically Significant Improvement
Pre- to Post- Treatment by Treatment Conditiona
Improved
No Change
Worse
aX2
BT PE
BT-PE
BT PS
BT-PS
C
Counseling
li
WLC
N = 23
N = 19
N=10
N = 20
52%
48%
0
68%
32%
0
20%
60%
20%
20%
75%
5%
(6, N = 72) = 18.48; p < .005
Depression in Dementia
Subjects in Behavior Therapy:
Clinically significant treatment gains maintained
at 6 month follow up
relapsed
l
d
31%
maintained or
improved
further
69%
Treatment
m
of
f D
Depression
p
in
Dementia
Pharmacologic Approaches:
SSRI’s
SSRI s first line of
f pharmac
pharmacologic
l ic treatment
often effective as part of an overall program of care
Other antidepressants are fine too
trazodone can help agitation, anxiety, sleep disturbance
Avoid
d Tricyclic
T
l Antidepressants
d
anticholinergic side effects exacerbate cognitive impairment
A Psychosocial Treatment for Depression
in Nursing Homes
• 31 residents with major or minor depression,
mild
m
ld to moderate sever
severity
ty
• No or mild cognitive impairment
• 6 weeks of self-chosen activities (“controlrelevant” intervention) vs
relevant
vs. standard care
Rosen et al. AJGP. 1997
Rosen et al, 1997
R
Results
l
• Typical program: 2-3 activities per week,
games,
m , discussion
1.5 hours each—card g
groups, lunch outings
– Family often involved
• Results: 45% remission rate, 0% during
standard care
Rosen et al. AJGP. 1997
Rosen et al, 1997
Antidepressant Drug Therapy
Alone: Is It Adequate?
• “Oldest-old” study – patients with nonpsychotic
p
y
major
j depression,
p
, mean Ham-D
score = 24, not demented
79 n = 174 (145 completed)
• Mean age 79,
• 15 sites
• Citalopram
Cit l
10 – 40 mg/day
/d
R
Roose
ett al,
l 2004
No.
N
Main effect for site, not treatment
Roose et al, 2004
Virtual site: 7 of 15 sites enrolling 8 or fewer patients; data combined.
Bereavement-Induced Major Depression:
What’ss the Best Treatment?
What
80
% remission
% withdrawn
60
40
20
0
NT + IPT
NT
IPT
Placebo
Reynolds et al, 1999
Relapse Prevention: Best Practice
3-Year Follow-Up*
% Recurrrence
90
80
70
60
50
40
30
20
10
0
Placebo
IPT +
Placebo
NT
NT + IPT
*All visits were monthly; IPT = interpersonal psychotherapy;
NT = nortriptyline.
Reynolds et al, 1999
Choosing the Best Treatment for
the Patient
• Define clinical features
– Depressive
p
subtype
yp matters
• Understand co-occurring medical
conditions and concurrent drugs
g
• Assess individual vulnerability to poor
outcome
• Define goals and preferences (patient,
family)
y)
Family Complaint
Consult Request
Patient Complaint
Depression in Older Person
What do you see?
Mood
Behavior Cognition
Is it a mood disorder?
No
Yes
Make ssyndromal
ndromal diagnosis
What is it?
Major depression
Sickness
Si
k
Behavior
Other depression
C
Cognitive
iti Di
Disorder
d
Delirium
Assess personal/family
history of mood d/os
Evaluate current
compounding factors
Dementia
Appropriate
Intervention
Differential Diagnosis
Medical Problems
Psychosocial Stressors
Medical Treatments
TREATMENT
When The Treatment Is Wrong
• Premature discontinuation of care
• Confusing, prolonged search for efficacy
• Poor
P
adherence
dh
to generall medical
di l care
• Unwise use of ancillary medications
– Especially anxiolytics, hypnotics, over-the-counter
medications
sk of adverse events
– May add to rrisk
• Substance abuse, especially alcohol
• Increased family and caregiver burden
• Suicide
Other Interventions That Support
pp
Treatment
• Healthy habit reinforcement
– Regular social interaction
– Exercise
E
– Appropriate medical care
– Congruent spiritual or wisdom practices
• Prevent and manage chronic diseases and
health risk factors
• Manage persistent disability
Causes of Persisting Disability in Treated LateLatelife Depression (n = 152)
CIRS-G
10%
Exec
Dysfunction
(striatofrontal)
Age
38%
17%
HDRS-R
13%
Gender
22%
Courtesy of G. Alexopoulos
Subcortical Vascular Depression:
MRI Examples
White matter ischemia
Strategic lacunes
Residual Disability in Late
Late-life
life
Depression
• Mood disorder can be distinguished
from
f
m disability
y
• Assess both individually
• Older patients frequently have
persisting disability after bestavailable treatment f
for depression
p
• Managing disability improves quality of
life
D li with
Dealing
i h Residual
R id l Di
Disability
bili
• For cognitive disability
– Executive prostheses
• Time structure, caregiver support
• For
F medical
di l di
disability
bilit
– Optimize collaboration with physicians
• For physical disability
– Rehabilitation, exercise retraining
– Pain control
• For
F social
i l iimpoverishment
i h
t and
d isolation
i l ti
– Enrich contacts - enlist family, paid caregivers
g options
p
– Shared housing
– Individualized group support programs (e.g. widows’ groups;
adult day programs)
Resources for Additional
Information
• Alliance for Aging Research
– www.agingresearch.org/depression/
www agingresearch org/depression/
• American Psychological Association
– www.apa.org
www apa org
• American Association for Geriatric Psychiatry
– www.aagponline.org
www aagponline org
• National Institutes of Health
– www.clinicaltrials.gov