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: J l E St i MD Joel E. Streim, MD

Source Grant / Research Support

National Institute for Mental Health (NIMH)

X

( ) VA HSR&D

X

Health Resources and Services Administration (HRSA)

X

Administration (HRSA) National Institute on Aging (NIA)

X

2

Learning Objective

f Identify and evaluate the dimensions

• f 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 i d i t depression and anxiety

• Approaches to assessment, with an emphasis
• n 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

A i By addressing morbidities that are associated with poorer treatment response and outcomes

• Anxiety
• 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

f – Presence of hopelessness – 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 disturbance1 Oth i t t b i t d ith

• Other anxiety symptoms may be associated with

depression2

W – Worry – 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 changes1

Cognitive changes

– Memory complaints – Executive dysfunction not solely attributable to impaired t ti concentration

• Functional decline

– Disengagement from usual activities2 not solely attributable to Disengagement from usual activities not solely attributable to anhedonia – Impaired performance of activities of daily living3 not solely attributable to loss of interest attributable to loss of interest – Self-neglect3 not solely attributable to hopelessness or giving up – Poor oral intake4 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 value1 prognostic value

• PHQ-9 and GAD-7 are sensitive to treatment

effects over time1,2 effects over time1,2

• Dimensional measures can inform care

management/individualized care1 management/individualized care1

• Objective evidence of treatment benefits can

be used to support patient adherence2 be used to support patient adherence2

PHQ-9, Patient Health Questionnaire-9; GAD-7, Generalized Anxiety Disorder-7.

• 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. y

Tool Kit of Standardized Assessment Instruments

Please see your handouts for more detailed descriptions of these tools

• PHQ-9
• GAD-7

G i i D i S l (GDS)

• Geriatric Depression Scale (GDS)
• Hospital Anxiety and Depression Scale (HADS)
• Paykel Suicide Scale

y

• PTSD checklist
• AUDIT-C

B i f P i I t

• Brief Pain Inventory
• 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 Depression Severity Total Score Depression Severity 0-4 No depression 5-9 Mild 10-14 Moderate 10-14 Moderate 15-19 Moderately severe 20-27 Severe Mrs Sensperanza’s score is: 13

Kroenke et al. J Gen Intern Med. 2001;16(9):606-613.

Mrs Sensperanza’s score is: 13

Mrs Sensperanza’s GAD 7 S GAD-7 Score

GHD-7, General Anxiety Disorder Questionnaire P i i di Permission pending.

GAD-7 Scoring for Anxiety Severity

GAD-7 Total Score Anxiety Severity 0-4 Minimal 5-9 Mild 10-14 Moderate 10-14 Moderate 15-21 Severe

• Mrs. Sensperanza’s score is: 18

Spitzer et al. Arch Intern Med. 2006;166:1092-1097.

Recognition of E ti D f ti Executive Dysfunction

• History of observable functional and

History of observable functional and behavioral signs1

– 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
• ccupational therapist2
• ccupational 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