Evaluating Dimensions of Geriatric Depression and Anxiety Geriatric - PowerPoint PPT Presentation

Evaluating Dimensions of Geriatric Depression and Anxiety Geriatric Depression and Anxiety Joel E. Streim, MD Professor, Psychiatry Geriatric Psychiatry Section University of Pennsylvania VISN 4 MIRECC VISN 4 MIRECC Philadelphia VA Medical Center Philadelphia, Pennsylvania Philadelphia, Pennsylvania

Faculty Disclosure: Joel E. Streim, MD J l E St i MD Source Grant / Research Support National Institute for Mental Health X ( (NIMH) ) X VA HSR&D X Health Resources and Services Administration (HRSA) Administration (HRSA) National Institute on Aging (NIA) X 2

Learning Objective Identify and evaluate the dimensions f of geriatric depression and/or anxiety, using measurement-based principles

Dimensions of Geriatric Depression and Anxiety: Themes and Topics • Key dimensions relevant to clinical assessment of elderly patients with d depression and anxiety i d i t • Approaches to assessment, with an emphasis on measurement tools • Multidimensional assessment and Multidimensional assessment and measurement to facilitate individualized treatment

Why Is Multidimensional Assessment Important? Helps us individualize treatment Helps us individualize treatment - Pharmacotherapy - Learning-based psychotherapies By addressing morbidities that are associated with poorer treatment response and outcomes • Anxiety A i • Suicidal ideation • Pain Pain • Sleep disturbance • Nutritional compromise • Executive dysfunction Katz et al. J Geriatr Psychiatry Neurol. 1993;6(3):161-169.

Key Dimensions of Assessment • Baseline measures of depression and anxiety symptoms – Presence of hopelessness f – Suicidal ideation • Inventory of clinically relevant comorbidities – Medical conditions – Substance use or abuse – Cognitive impairment • Functional status measures – Basic activities of daily living (BADL) – Instrumental activities of daily living (IADL) Courtesy of Joel E. Streim, MD

Key Dimensions of Assessment (cont) y ( ) • Evaluation of psychosocial support – Availability and quality of care giving • Appraisal of patient and family attitudes • Appraisal of patient and family attitudes toward treatment, including risk tolerance tolerance – Likelihood of treatment engagement and adherence adherence – Barriers that require addressing Courtesy of Joel E. Streim, MD

Approaches to Assessment Focus on Common Presentations of Depression and Anxiety in Older Adults • Caregivers may report irritability or hostility as • Caregivers may report irritability or hostility as the predominant affective disturbance 1 • Other anxiety symptoms may be associated with Oth i t t b i t d ith depression 2 – Worry W – Obsessive ruminations – Panic symptoms – Posttraumatic stress symptoms – Somatic preoccupation/delusions 1. Monfort. Int Psychogeriatr . 1995;7(suppl):95-111. 2. Lenze. Curr Psychiatry Rep . 2003;5(1):62-67.

Approaches to Assessment Focus on Common Presentations of Focus on Common Presentations of Depression and Anxiety in Older Adults (cont) • Somatic complaints – Typical depression/anxiety symptoms • Sleep, appetite, energy – Exacerbation of symptoms of comorbid medical conditions conditions • Pain, dyspnea, dysgeusias, constipation, dizziness, weakness, undernutrition • Substance use comorbidity – At-risk alcohol use – Illicit or prescription drug misuse Lapid, Rummans. Mayo Clin Proc . 2003;78:1423-1429.

Approaches to Assessment Focus on Common Presentations of Depression and Anxiety in Older Adults (cont) • Cognitive changes 1 Cognitive changes – Memory complaints – Executive dysfunction not solely attributable to impaired concentration t ti • Functional decline – Disengagement from usual activities 2 not solely attributable to Disengagement from usual activities not solely attributable to anhedonia – Impaired performance of activities of daily living 3 not solely attributable to loss of interest attributable to loss of interest – Self-neglect 3 not solely attributable to hopelessness or giving up – Poor oral intake 4 not solely attributable to loss of appetite 1. Lockwood et al . Am J Psychiatry . 2002;159:1119-1126. 2. Tsai et al. J Chin Med Assoc . 2009;72(9):478-483. 3. Pavlou, Lachs. J Gen Intern Med . 2008;23(11):1841-1846. 4. Patel, Martin. J Nutr Health Aging . 2008;12(4):227-231.

Benefits of Standardized Measurement • Severity of symptoms (eg, anxiety, pain) has prognostic value 1 prognostic value • PHQ-9 and GAD-7 are sensitive to treatment effects over time 1,2 effects over time 1,2 • Dimensional measures can inform care management/individualized care 1 management/individualized care 1 • Objective evidence of treatment benefits can be used to support patient adherence 2 be used to support patient adherence 2 PHQ-9, Patient Health Questionnaire-9; GAD-7, Generalized Anxiety Disorder-7. y 1. Roman, Callen. Issues Ment Health Nurs . 2008;29(9):924-941. 2. Roy-Byrne et al. J Am Board Fam Med. 2009;22(2):175-186.

Tool Kit of Standardized Assessment Instruments Please see your handouts for more detailed descriptions of these tools • PHQ-9 • GAD-7 • G Geriatric Depression Scale (GDS) i i D i S l (GDS) • Hospital Anxiety and Depression Scale (HADS) • Paykel Suicide Scale y • PTSD checklist • AUDIT-C • B i f P i Brief Pain Inventory I t • Short-form McGill Pain Questionnaire-2 (SF-MPQ-2) • Pittsburgh Sleep Quality Index (PSQI) g p y ( ) • Barthel Index

Mrs Sensperanza’s PHQ 9 S PHQ-9 Score PHQ, Patient Health Questionnaire http://www.americangeriatrics.org/educatio n/dep_tool_05.pdf. Accessed January 21, 2010.

PHQ-9 Scoring for Depression Severity Total Score Total Score Depression Severity Depression Severity 0-4 No depression 5-9 Mild 10-14 10-14 Moderate Moderate 15-19 Moderately severe 20-27 Severe Mrs Sensperanza’s score is: 13 Mrs Sensperanza’s score is: 13 Kroenke et al. J Gen Intern Med . 2001;16(9):606-613.

Mrs Sensperanza’s GAD 7 S GAD-7 Score GHD-7, General Anxiety Disorder Questionnaire P Permission pending. i i di

GAD-7 Scoring for Anxiety Severity GAD-7 Total Score Anxiety Severity 0-4 Minimal 5-9 Mild 10-14 10-14 Moderate Moderate 15-21 Severe Mrs. Sensperanza’s score is: 18 Spitzer et al. Arch Intern Med . 2006;166:1092-1097.

Recognition of E Executive Dysfunction ti D f ti • History of observable functional and History of observable functional and behavioral signs 1 – Difficulty with initiation y – Inability to perform sequential tasks – Poor task completion Poor task completion – Disengagement from activities – Task avoidance (BADL IADL) – Task avoidance (BADL, IADL) • Referral for evaluation of functional status by occupational therapist 2 occupational therapist 1. Alexopoulos . J Clin Psychiatry . 2003;64(suppl 14):18-23. 2. Erez et al. Am J Occup Ther. 2009;63(5):634-640.

Conclusion Dimensional assessment of geriatric depression and anxiety is important because it enables us to individualize treatment . • Reveals patient characteristics and needs that may influence – Treatment choices and planning – Engagement g g – Adherence – Response – Tolerability Tolerability • Identifies comorbidities to be addressed by care management/ learning-based psychotherapies • Targets problem areas that require family and caregiver support for treatment