depression and anxiety in later life clinical challenges and creative research

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1 2 nd Annual MARC Symposium Critical Themes in Ageing Melbourne, 10 th August 2018 depression and anxiety in later life clinical challenges and creative research Nicola T Lautenschlager, MD, FRANZCP Professor of Psychiatry of Old Age, University of Melbourne Director of the Academic Unit for Psychiatry of Old Age (AUPOA) Director of Research, APMHP, NorthWestern Mental Health, MH nicolatl@unimelb.edu.au

2 Mood: what is normal? It is normal to experience positive and negative emotions Sadness is a normal human emotion, particularly when under stress A clinical condition may be considered when this becomes severe and prolonged and affects a person s function

3 What is depression?

4 Stress-vulnerability model Stressors LIFE Resilience

5 Ten leading causes of burden of disease World Health Organisation

6 Burden of disease in Australia: AIHW 2016

7 Depressive disorders Major Depressive Disorder Melancholic Non-Melancholic / Reactive Psychotic Atypical Dysthymia Secondary to general medical condition Substance induced

8 Major depression episode DSM 5 A. Five (or more) of the following symptoms present during the same 2-week period nearly every day and a change from previous functioning. Depressed mood most of the day Markedly diminished interest or pleasure in all, or almost all, activities most of the day Significant weight loss when not dieting or weight gain Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or loss of energy Feelings of worthlessness or excessive or inappropriate guilt Diminished ability to think or concentrate, or indecisiveness Recurrent thoughts of death (not just fear of dying), suicidal ideation B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The episode is not attributable to the physiological effects of a substance or another medical condition. (Adapted from DSM )

9 RANZCP: mood disorder specifiers

10 RANZCP: bio-psycho-social and lifestyle model

11 RANZCP: Mood disorders: stages of illness and phases of treatment

12 RANZCP: strategies to address medication non-response

13 Prevalence of depression in older adults 2007 National Survey of Mental Health and Wellbeing - Community (Trollor, Anderson, Sachdev, Brodaty, Andrews Am JGP 2007) Face-to-face household survey (n=1792) of 65yo + using the CIDI via ABS lay interviewers: 12 month prevalence of depression % and dysthymia % More common in females compared to males with OR = 2.4 Systematic Review of Psychiatric Disorders among Older Adults in Long- Term Care Homes (Seitz, Purandare, Conn 2010 Int Psychogeriatrics) Median prevalence of major depressive disorder of 10% Median prevalence of depressive symptoms of 29%

14 Risk of major depression in old age Most common mental health condition 10-15% of older adults have depressive symptomatology 3% have DSM/ICD depression Healthy older adults not at greater risk, but medical conditions increase risk Prevalence in nursing homes and hospitals higher Rates are higher for older adults with cognitive problems

15 Features in older adults May minimise symptoms due to stigma or generational differences in expressing emotion Symptoms of physical and psychiatric conditions may overlap, eg. changes in appetite or energy levels May present with less expression of sadness May present with more: somatisation/hypochondriasis psychosis insomnia melancholia psychomotor agitation/retardation, non-interactiveness guilt May present with Pseudodementia Depression may be superimposed on dementia

16 Aetiology of late life of depression Genetics Sex Age related physiological or anatomical change Physical illness/disability Substance use and iatrogenesis Personality factors Social factors Adverse life events

17 Social factors Isolation Loss of loved ones Entry to residential care Personal experience of Ageing Loss of social roles Move Carer role Family conflict/ elder abuse Societal view of ageing

18 Iatrogenisis

19 Glucocorticoid theory Major depression is associated with cortisol elevation Sustained hypercortisolaemia is toxic to the hippocampus In these patients, the hippocampus becomes particularly vulnerable to neurodegenerative pathology in old age Here, depression is an independent risk factor for dementia Depression Dementia

20 Depression as risk factor Ashby-Mitchell et al., 2017

21 Vascular hypothesis With increasing age, there is increasing cerebrovascular pathology in the brain Vascular depression can accompany vascular cognitive impairment/vascular dementia. Here, depression is not an independent risk factor for dementia. Vascular disease Depression Dementia

22 Vascular depression Late onset depression Reduced depressive ideation (e.g. guilt) Reduced insight More overall morbidity Apathy and retardation More cognitive impairment Poorer recovery from depression

23 Neurodegenerative hypothesis Neurodegenerative disease causes cognitive impairment/dementia Neurodegenerative disease also causes apathy, anxiety, depression, and other behavioral disturbance These behavioral disturbances precede or accompany MCI and may be the first sign of the dementia Neurodegeneration Depression Dementia

24 Challenges in residential care Moving into RACF is often a significant life stress and may occur in the context of major changes to health and function Adjustment, grief and loss issues may be prominent Higher prevalence of depression in this setting Depression may be under-recognised Often have co-morbid diagnoses that cause functional impairments including physical and cognitive Less access to psychosocial interventions, including psychological interventions

25 Depression in dementia - RANZCP recommendations

26

27 What is Anxiety? A feeling of worry, nervousness, or unease about something with an uncertain outcome From Latin to choke Source: Oxford English Dictionary

28 Is anxiety good or bad? Brain directs a staying alive machine If in danger, the body wants to make sure we don t ignore it Hence the fight flight sympathetic nervous system response

29 Anxiety disorders Specific Phobia Social Anxiety Disorder Panic Disorder Agoraphobia Generalised Anxiety Disorder Secondary to general medical condition Substance induced Obsessive-Compulsive Disorder

30 30

31 31

32 32

33 Amyloid and anxiety RH Pietrzak et al., 2015

34 Treatment of anxiety Lifestyle, diet and exercise First line is psychotherapy with most evidence favouring CBT including psychoeducation, relaxation techniques, activity scheduling, lifestyle modification, problem solving Pharmacotherapy evidence favours SSRIs and SNRIs Benzodiazepines should be avoided or only used short-term OCD First line is CBT including exposure & response prevention Pharmacotherapy is SSRI or Clomipramine

35 Treatment of anxiety: what works in older age? 35 Ramos et al., 2018

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