Introduction: Geriatric Depression Introduction: Geriatric Depression and Anxiety—Neglected Conditions Charles F. Reynolds III, MD y UPMC Endowed Professor in Geriatric Psychiatry University of Pittsburgh Medical University of Pittsburgh Medical Center Senior Associate Dean University of Pittsburgh School of Medicine Pittsburgh Pennsylvania Pittsburgh, Pennsylvania
A Tragic Misconception A Tragic Misconception “Health professionals may mistakenly think that persistent depression is an acceptable response to persistent depression is an acceptable response to other serious illnesses and the social and financial hardships that often accompany aging—an attitude often shared by older people themselves. This contributes to low rates of diagnosis and treatment in older adults.” older adults. —National Institute of Mental Health Depression and anxiety are not inevitable aspects of aging Depression and anxiety are not inevitable aspects of aging National Institute of Mental Health. Older Adults: Depression and Suicide Facts. http://www.nimh.nih.gov/health/publications/older-adults-depression-and-suicide-facts-fact- sheet/index.shtml. Accessed January 4, 2010.
Geriatric Depression: Epidemiology Epidemiology • 15% of older adults (age ≥ 65 years) suffer from depression symptoms 1 y p • 1% to 2% have major depressive disorder (MDD) 1 • Only 14% of nursing home patients with diagnosed depression ha e disorder doc mented in their charts 2 have disorder documented in their charts 2 • An estimated 5 million have subsyndromal depression, symptoms that fall short of full diagnostic criteria for a disorder 3 • Suicide rate almost twice that of general population 1 • More likely to receive inadequate/inappropriate treatments 4 1. Alexopoulos et al. Depression in Older Adults: A Guide for Patients and Families. Expert Knowledge Systems, LLC, and Comprehensive Neuroscience, Inc; 2001. 2. Wagenaar et al. J Am Osteopath Assoc. S LLC d C h i N i I 2001 2 W l J A O h A 2003;103(10):465-469. 3. National Institute of Mental Health. Older Adults: Depression and Suicide Facts . http://www.nimh.nih.gov/health/publications/older-adults-depression-and-suicide-facts-fact-sheet/index.shtml. Accessed January 4, 2010. 4. Bartels et al . Psychiatr Serv. 2002;53(11):1419-1431.
Consequences of Depression Consequences of Depression • Increased functional impairment Increased functional impairment • Higher health costs • Increased mortality rates – Suicide – Complications of cardiac disease • Increased secondary symptoms (eg, pain) y y p ( g, p ) • Decreased health-related quality of life Snowden et al. Prev Chronic Dis . 2008;5(1):A26.
Anxiety: The “Silent Giant” Anxiety: The Silent Giant • 10% to 20% among older adults • Twice as prevalent as dementias T i l t d ti • 4 to 8 times as prevalent as MDD • Types of anxiety disorders – Generalized anxiety disorder (at least 50% of anxiety cases) i ) – Specific phobias – Obsessive-compulsive, posttraumatic stress Ob i l i tt ti t disorder, panic • 50% to 97% are early onset disorders with • 50% to 97% are early-onset disorders with late-life exacerbations Cassidy et al. Geriatr Aging. 2008;11(3):150-156.
Comorbid Depression and Anxiety Anxiety • Up to 65% of older adults with depression p p have comorbid symptoms of anxiety 1 • More severe presentation of depressive More severe presentation of depressive illness (including suicidality) 1 • Poorer treatment outcomes 1 Poorer treatment outcomes • Delayed/diminished response to treatment 1 • Increased likelihood of nonadherence 1 1 • Increased disability 2 1. Lenze. Curr Psychiatry Rep . 2003;5(1):62-67. 2. Diefenbach, Goethe. Clin Interv Aging . 2006;1(1):41-50.
Specific Geriatric Presentations Specific Geriatric Presentations • Triggers and exacerbators – Increasing frailty 1 g y – Medical illness 1 – Losses 1 – Lack of social supports 1 ac o soc a suppo ts – Recent traumatic events 1 – Inadequate financial resources 2 • Behavioral/emotional manifestations Behavioral/emotional manifestations – Hoarding 3 – Complicated grief 4 – Self-neglect 5 – Self-neglect – Failure to thrive 6 – Fear of falling 7 1. Cassidy et al. Geriatr Aging . 2008;11(3):150-156. 2. Choi, McDougall . J Gerontol Soc Work . 2009;52(6):567- 583. 3. Maier. Acta Psychiatr Scand . 2004;110(5):323-337. 4. Alty. Nurs Times. 1995;91(12):34-36. 5. Pavlou, Lachs. J Gen Intern Med . 2008;23(11):1841-1846. 6. Rocchiccioli, Sanford. J Gerontol Nurs . 2009;35(1):18-24. 7. Filiatrault et al. Arch Phys Med Rehabil . 2008;89(10):1948-1957.
Case Vignette: Mrs Sensperanza Case Vignette: Mrs Sensperanza • Gender: Female G d F l • Age: 83 years • Age: 83 years • Status: Lives alone in an apartment near her p daughter
Presenting Complaint as Stated by Her Daughter Stated by Her Daughter – “Mom’s down all the time these days. She just sits around, and doesn’t even watch TV.” – “She used to love playing with her grandchildren. Lately, she hardly pays any attention to them.” – “She used to love cooking. Now, she eats dry bread or cold leftovers. I think she skips meals—she’s lost 11 p pounds in the last few months.” – “She uses speed dial to call me 10 times a day to make She uses speed dial to call me 10 times a day to make sure I’m OK. If I don’t pick up, she gets angry. She never had such a temper before.” – “Her apartment is a mess. She used to be a neat freak, but now there’s stuff all over the place.”
Presenting Complaint as Stated by Patient – “I don’t know why my daughter’s making such a fuss. I’m not ‘down.’ I don t know why my daughter s making such a fuss. I m not down. TV today stinks, and it’s just not interesting.” – “I love the grandchildren but they get on my nerves making noise I love the grandchildren, but they get on my nerves, making noise and running around. I also worry they’ll fall and get hurt.” – “Cooking is too much bother There’s nothing wrong with cold food Cooking is too much bother. There s nothing wrong with cold food. And why do I need to eat three meals a day?” – “I am annoyed when she doesn’t answer the phone. What if “I d h h d ’t th h Wh t if something terrible happened to her? Or what if I fell and couldn’t reach her? She should be more considerate!” – “You young people don’t understand what it’s like to be my age. It’s normal to worry.” – “It’s too hard to keep up with the housework. I’d like to see you clean your house when your knees and hips are hurting!”
Mrs Sensperanza: Exam • Medical History – Hypertension – Hyperlipidemia – Moderate osteoarthritis with bilateral hip/knee pain – No prior episodes of depression, substance abuse • Medication History – Hydrochlorothiazide 25 mg qd – Lisinopril 10 mg qd – Atorvastatin 10 mg qhs – Naproxen 200 mg bid prn for knee pain – Aspirin 81 mg qd
Mrs Sensperanza: Exam (cont) • Mental Status – Alert, attentive, fully oriented Al i f ll i d – Little spontaneous conversation – Moderate psychomotor restlessness – Affect is alternately irritable and apprehensive – No psychosis, hopelessness, suicidal ideation • MMSE Score: 28/30 – Delayed recall: 2 of 3 correct – 3-Step command: 2 of 3 correct p MMSE, Mini-Mental State Examination
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