Assessment and Treatment of Depression in Late Life

1. Assessment and Treatment of Depression in Late Life SarraNazem Jay Gregg Patty Bamonti West Virginia University

2. Overview of Presentation • Information about late-life depression and comorbid disorders • Assessment of late-life depression • Treatment of late-life depression • Vignettes and group collaboration!

3. Depression in Late Life

4. What unique stressors might older adults face? • Retirement • Widowhood • Care-giving • SES w/ reduced income • ↑ health care costs • End of life planning • Disability • Visual, Auditory, Cognitive impairment • Continence

5. Psychological symptoms and disorders in older adults • 20-30% have a psychological disorder • Psychological symptoms are not a normal part of aging • Ageism • Mental Health Specialists? • Psychological disorders are treatable! • Physical symptoms > psychological symptoms • Comorbidity

6. What are the prevalence rates of depression in older adults? • ~1% diagnosed w/ major depression • ~4% w/ dysthymia • BUT, 15% have sub-threshold symptoms • Associated with cognitive impairment, social/functional impairment, risk of suicide, poorer health outcomes, and overall mortality

7. Special populations • Rates of depression are higher in some groups: • Medical inpatients: 10-15% • Nursing home residents: 14-42%

8. Symptoms of Major Depression: • Depressed Mood • Loss of pleasure/interest in activities • Appetite disturbance • Sleep disturbance • Fatigue or loss of energy • Difficulty concentrating • Feelings of worthlessness/guilt • Psychomotor agitation/retardation • Thoughts of death or suicide

9. How does it differ for older adults? • “Depression without sadness” • More likely to endorse or exhibit: • Forgetfulness/difficulty concentrating • Psychomotor retardation • Psuedodementia

10. Medical conditions and late-life depression • Stroke • Cardiovascular disease • Vascular depression • Parkinson’s disease • COPD

11. Depression and Dementia • Depression of Alzheimer’s Disease • Social withdrawal • Irritability • Dementia and Vascular depression • Vegetative symptoms

12. Comorbid Psychological Disorders • Anxiety • Substance Abuse • Insomnia

13. Substance abuse • Underestimated problem! • Alcohol, prescription drugs, tobacco abuse most common • Drinking problems not noticed until: • Dependence on others • Interacts with medical illnesses/treatment • What’s normal/acceptable? • Medication issues

14. Prevalence & Impact of SA in OA • Lower prevalence than younger adults, but… • Problematic/risky drinking vs. Alcohol abuse • 12-15% compared with 0.7-4.6% • Symptoms milder, less family history • 25% • As we get older, can’t metabolize drugs • Problems= falls, impotence, delirium, dementia, dehydration, gait problems, drug interactions

15. Demographics & Etiology • Men 2x women, ~15% problem drinkers • Prescriptions drugs = women • Ethnicity needs to be studied • Etiology? • Same as younger adults • Late-onset = environment > genetics

16. Sleep in Late Life • Insomnia more prevalent in older adults than any other age group • 50% of older adults complain of sleep difficulties • Why? • Changes in circadian rhythms • Increased medical illnesses (pain, GERD, apnea) • Medications that affect sleep • Other psychosocial factors • Older adults often struggle without complaint/report to health care professionals

17. Suicide in Late Life What factors contribute to the high risk for suicide for older adults?

18. Suicide in Late Life • Attempt to death ratio = 4:1 (overall = 25:1) • Female to male attempt ratio = 3:2 (overall = 3:1) • Risk factors • Chronic illness • Decreased social support • Late life depression • Others? • Gender differences • Race/Ethnicity differences

19. Assessment

20. Who is at risk?

21. Assessment: How Often? • Community-Dwelling • Age 60+: Screen periodically • Nursing Home Residents • 2 to 4 weeks after admission • Repeated screening at least every 6 months

22. Diagnostic Criteria • Must include: • Dysphoria and/or anhedonia • Other symptoms: • Appetite disturbance, sleep disturbance, low energy, psychomotor retardation/agitation, inability to concentrate, feelings of worthlessness/guilt, thoughts of death or suicide • Impairment • Not due to bereavement, medical condition or substance

23. Multidimensional Assessment • Adaptive functioning • Physical health • Diseases, Medications • Cognitive functioning • Social support

24. Case Example: Kevin • Besides assessing for depression, what other factors would you want further information on? • How might Kevin’s lack of social support play a role in his depression?

25. Multi-Method Assessment • Self-report • Report-by-others • Clinician rating • Direct observation

26. Case Example: Susan • How would you handle this situation? • Why might Susan’s report differ from the staff report?

27. Self-Report • Beck Depression Inventory (BDI) • 21-item, 4-point scale • Somatic, affective and cognitive components • BDI-II: OA included in normative sample • Geriatric Depression Scale (GDS) • 30 item, yes/no format • Excludes somatic items • GDS-SF: 15 item available • Center for Epidemiological Studies – Depression Scale (CES-D) • 20-item, 4 point scale • CESD-R: More aligned with DSM-IV

28. Clinician Rating Scales • Hamilton Rating Scale for Depression (HRSD) • Geriatric Depression Rating Scale • 35-items • Inventory of Depressive Symptomology (IDS) • 28-items, 0-3 rating scale • Cornell Scale for Depression in Dementia (CSDD) • 19-items, 3-point rating scale

29. Assessment Strategy • Screen with self-report • GDS, CESD, BDI • Clinical interview/behavioral assessment • Collateral interview/information • Functional assessment

30. Screening: Cognitive Impairment • Administer cognitive screening instrument • Mini-Mental State Exam (MMSE) • Acute change? • Administer depression screening instrument • If MMSE = 15-23: GDS-SF • If MMSE < 15: Cornell Scale (CSDD) • Follow-up • GDS-SF ≥ 6 or CSDD ≥ 11: Referral • GDS-SF ≤ 5 or CSDD ≤ 11: Reassess in 1 month if clinically indicated

31. Suicide Assessment • Suicidal Older Adult Protocol (SOAP) • Assess risk among several factors • Demographic • Historical • Clinical: Stable and Acute • Contextual • Protective • Severity ratings

33. Alcohol Assessment • Screening Instruments • CAGE questionnaire • Alcohol-use disorders identification test (AUDIT) • Short Michigan Alcohol Screening Test-Geriatric version (SMAST-G) • Alcohol-Related Problems Survey (ARPS) • Functional Assessment

34. CAGE • Have you ever felt you should Cut down on your drinking? • Have people Annoyed you by criticizing your drinking? • Have you ever felt bad or Guilty about your drinking? • Have you ever had a drink first thing in the morning to steady your nerves or get over a hangover (Eye opener)? Ewing 1984

35. Treatments for Late Life Depression

36. Empirically-Support Treatments • What psychotherapies have been validated in older adults? • What are the active ingredients of these therapies? • How can these therapies be adapted to patients with cognitive impairment or dementia? • How can treatments be adapted to include co-morbidities, such as substance use, chronic pain, and/or insomnia?

37. What psychotherapies have been validated in older adults? • “Traditional” Cognitive Behavior Therapy (CBT) • Problem-Solving Therapy (PST) • Interpersonal Therapy (IPT)

38. What psychotherapies have been validated in older adults in the treatment of depression? • Cognitive Behavior Therapy (CBT) • Goal: Increase patient’s access to positive reinforcers and teach the patient how to identify, test, and restructure negative automatic thoughts. • Focus of therapy: skill building, cognitive restructuring, and setting & consequences associated with behavior and mood.

39. What are the active ingredients of these therapies? • CBT • Behavioral activation • Identify pleasant events • Pleasant event scheduling • Mood tracking • Track outcomes • Goal: Demonstrate the relation between engaging in activities and mood.

40. Event Tracking

41. Mood Tracking

42. What are the active ingredients of these therapies? • CBT • Cognitive Restructuring • Introduce what negative thoughts are and how they relate to an individual’s mood and behavior. • Introduce styles or patterns of response or styles of thinking and provide some examples. e.g. Black/white thinking, overgeneralization, personalization, “shoulds”, emotional thinking. • Engage in in-session and out-of-session identification of situations that trigger negative thoughts, the thought content, and the emotional and behavioral consequences. • Test thoughts/modify thoughts

43. 3-Column 6-Column

44. Case Example Claire is a 67-year-old widowed African American female living in rural West Virginia. She was referred to you by her primary care provider who she has seen for over 30 years because of noncompliance to her diabetes regimen, lack of interest in her usual activities, irritability, and low mood, which began about 6 months ago. Upon meeting Claire for an intake interview, she is polite, but guarded. When asked about her mood lately, Claire states that she “Just wants people to leave her be” and that “I’m an old woman, there’s nothing left for me.” When asked about what she likes to do for enjoyment, she states that “There’s no point in going out, I won’t have a good time anyway “and “Who has use for an old lady like me now?” She also reports recently losing her license due to vision impairment and states that “I can’t go anywhere anyways even if I wanted to!” Upon further questioning, Claire reports that her daughter has recently moved in with her in order to help out around the house. Claire is angry over this and states that her daughter has “taken over.” She believes that she can manage on her own. Claire was diagnosed with Chronic Kidney Disease that is currently managed with medications about a year ago. • Elaborate on some of the CBT-based strategies you might use in therapy? • Can you think of any obstacles that may come about as you proceed in therapy with Claire?

45. What psychotherapies have been validated in older adults? • Problem-Solving Therapy (PST) • Goal: For the patient to identify adaptive means of coping with acute and chronic problems in life. • Focus: The patient is taught to direct their coping efforts directly towards changing the problematic nature of the situation and/or their reactions to the problem.

46. What are the active ingredients of these therapies? • PST • Problem orientation- a set of relatively stable cognitive-affective schemas that represent a person’s generalized beliefs, attitudes, and emotional reactions about problems in living and one’s ability to cope with problems. • Positive problem orientation • Negative problem orientation

47. What are the active ingredients of these therapies? • PST • Rational problem solving- constructive problem solving style that involves the systematic application of specific skills, each of which makes a distinct contribution toward the discovery of an adaptive solution or coping response. • Define problem • Generate alternative solutions • Decision making • Implementation and evaluation

48. Case Example • Define problem • Generate alternative solutions • Decision making • Implementation and evaluation

49. What psychotherapies have been validated in older adults? • Interpersonal Therapy (IPT) • Goal: Introduce alternate coping strategies in order to bring about therapeutic change. • Focus: Current interpersonal relationships in four broad areas: abnormal grief, role transition, role dispute, and interpersonal deficits.

50. What are the active ingredients of these therapies? • IPT • Identify and solve/manage interpersonal problems. • Emphasize present stressful events and mood. • Help patient identify emotions and how to use them to guide behavior in interpersonal relations.