Arizona Geriatrics Society 5th Annual Spring Geriatrics Multi-Disciplinary Conference EXPANDING YOUR GERIATRIC TOOLBOX Saturdays, May 5, 12, 19

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1 Arizona Geriatrics Society 5th Annual Spring Geriatrics Multi-Disciplinary Conference Teri Kennedy, PhD, MSW, LCSW, ACSW Director, Office of Gerontological Social Work Initiatives Arizona State University/School of Social Work 2012 Arizona Geriatrics Society Spring Conference Office of May 5, 2012 (Prescott, AZ) Gerontological May 12, 2012 (Sun City, AZ & Mesa, AZ) Social Work May 19, 2012 (Tucson, AZ Initiatives Describe the prevalence & presentation of geriatric depression Recognize the challenges of differential diagnosis Explain how depression is culturally constructed Compare & contrast common screening tools for geriatric depression Administer brief depression assessment instrument Formulate an action plan if a client/patient screens positive for depression Participants will be able to: Evaluate screening instruments for depression, including GDS-15, PHQ-9, and PHQ-2 Practice administering these brief depression screens

2 Arizona Geriatrics Society 5th Annual Spring Geriatrics Multi-Disciplinary Conference Most frequent cause of emotional suffering in later life Major depression: 10-16% older adults in general population Nursing home residents are particularly at risk for depression (16% major depression and another 16% significant depressive symptoms) Minor depression: 8-20% community-dwelling older adults/37% older adults in primary care settings Can be as disabling in its prevalence and impact as major depression in older adults Impact includes excess disability & reduced quality of life Often under diagnosed due to complex presentation Prevalence for women is twice as high as for men Life threatening, presenting a serious public health problem: Suicide rates 11.3 per 100,000 in general population Older adults have the highest risk of suicide of any age group Single, white, elderly males have the highest rate of suicide and are more likely to succeed than their female counterparts Biological Family history (genetic predisposition) Prior episode(s) of depression Aging changes in neurotransmission Physical Specified diseases Chronic medical conditions (especially with pain or loss of function) Exposure to drugs Sensory deprivation (loss of vision or hearing) Loss of physical function (Kane, Ouslander, & Abrass, 1994, p. 117)

3 Psychological Unresolved conflicts (e.g., anger, guilt) Memory loss and dementia Personality disorders Social Losses of family and friends (bereavement) Isolation Loss of job Loss of income (Kane, Ouslander, & Abrass, 1994, p. 117) Recognizing and diagnosing late-life depression can be difficult. Older patients may: Complain of lack of energy or other somatic symptoms Attribute symptoms to old age or other physical conditions, or Fail to mention their symptoms to a health care professional Minimal expression of sadness (understated complaints) Somatization or excessive physical complaints Overlap of physical and somatic psychiatric symptoms Unexplained pain syndromes Neurotic symptoms of recent onset Medically trivial acts of deliberate self-harm Pseudodementia Depression superimposed upon dementia Accentuation of abnormal personality traits Behavior disorder Late-onset alcohol dependency syndrome Loneliness Insomnia (Baldwin, 2010, p. 15)

4 Arizona Geriatrics Society 5th Annual Spring Geriatrics Multi-Disciplinary Conference Is it depression, dementia, or delirium? Is it early-onset or late-life depression? Depressive symptoms can be part of a psychological reaction to medical illness, disability, or discomfort A variety of illnesses & medications are associated with physiological changes that increase the susceptibility to depression These two factors can also interact Initial cognitive screening Screening for use of alcohol and other drugs, including prescription medications Rule out grief/bereavement, anxiety, etc. Alcohol and drug abuse Alzheimer s disease Cancer Cardiac illness Cerebrovascular disease Cerebral neoplasms Chronic pain Central nervous system infections (e.g., Lyme disease) Endocrine disorders (e.g., hypothyroidism) Nutritional deficits (e.g., vitamin B12 deficiency) Parkinson s disease Stroke Vascular dementia Viral and bacterial infections Vision loss (Blazer, 2002; Summings & Mega, 2003) People who are treated for type 2 diabetes have higher incidence rates of elevated depressive symptoms (Golden, Lazo, Carnethon, Bertoni, Schreiner, Roux, Lee, & Lyketsos, 2008) Beck Depression Inventory (BDI) Center for Epidemiological Studies Depression Scale (CES-D) Short version: CES-D-12 (Liang) & CES-D-10 Cornell Scale for Depression in Dementia Geriatric Depression Scale (GDS-30) Short version: GDS-15 Hamilton Rating Scale for Depression (HAMD) Patient Health Questionnaire (PHQ) Short versions: PHQ-2 & PHQ-9 Zung Self-Rating Depression Scale

5 21 item self-report instrument Answers scored on a 0 to 3 scale (minimal: 0; severe: 3) Designed to assess the existence and severity of symptoms of depression Sharp & Lipsky (2002) report mixed psychometric data, therefore BDI may not be the best screening measure for elderly patients No studies pertaining to the assessment of the BDI in minority populations SC Cooperative for Healthy Aging in Minority Populations, Resource Centers for Minority Aging Research (2006) 20 items (16 negative/4 positive) relating to depression Depressed mood, feelings of guilt & worthlessness, feelings of helplessness & hopelessness, psychomotor retardation, loss of appetite, & sleep disturbance Frequency-based four-point response options Translated into over 40 languages and frequently used in clinical trials Seven items failed to discriminate major, minor, and non-depressed patients in a study of medically ill elderly, therefore validity may be compromised when used with elderly medical patients (Schein & Koenig, 1998) Modified CES-D-12 (Liang) had better goodness of fit across three generations of Mexican-American elders Also available in a short form (CES-D-10) (Liang, Tran, Krause, & Markides, 1989) 19 item scale according to severity: absent, mild or intermittent, or severe Score of 8 or more suggests significant depressive symptoms Designed for assessing depression in elderly residents with dementia Includes ratings on information from interviews with the patient s caregiver and the patient, as well as observations of the patient Because individuals with dementia may have difficulty reporting on their experience of depression (due to deficits in memory, language, or insight), the other scales described here may not be valid for individuals with moderate to severe dementia Ratings based upon symptoms and signs occurring during the week prior to the assessment (except symptoms resulting from physical disability or illness) Mood-related signs, behavioral disturbance, physical signs, cyclic functions, ideational disturbance It was not developed as a diagnostic tool, but helps determine the severity of depressive symptoms

6 30 item scale with yes/no responses Scores: 0-9 normal; mild depression; severe depression Responses indicate how person felt on the day the instrument is administered May be used with healthy, medically ill, and mild to moderately cognitively impaired older adults Used extensively in community, acute, and long-term care settings Not a substitute for a diagnostic interview by a mental health professional A useful screening tool to facilitate assessment of depression in older adults, especially when baseline measures are compared with subsequent scores 24 item scale Designed to be administered by a trained clinician Many scale items were found to be poor contributors to the measurement of depression severity; other items had poor inter-rater and retest reliability; for many items, the format for response options was not optimal Evidence suggests that the scale is psychometrically and conceptually flawed (Bagby, Ryder, Schuller, & Marshall, 2004) Primary Care Evaluation of Mental Disorders (Prime-MD) is a diagnostic tool with modules on 12 different mental health disorders PHQ is a self-administered version of Prime-MD containing the mood, anxiety, alcohol, eating, and somatoform modules from the original instrument While self-administered, the tool is scored by a primary care clinician or office staff PHQ-9 is a tool specific to depression This 9 item depression scale is based upon and scores each of the 9 DSM-IV criteria for Major Depressive Disorder While not developed or tested to date with geriatric populations specifically, the tool can assist primary care clinicians to: Assess symptoms and functional impairment to make a tentative depression diagnosis, and Derive a severity score to help select and monitor treatment Further research is needed to study the PHQ s utility for diagnosing mental disorders in elderly primary care patients

7 20 question survey (score converted to 100 point scale) Likert Scale format: 1 to 4 scale (minimal: none or a little of the time; severe: most or all of the time) Self-assessment completed by patient Covers affective, psychological, and somatic symptoms associated with depression Half of questions asked negatively (I notice that I am losing weight) and half asked positively (I eat as much as I used to) <50: normal; <60: mild depression; <70: moderate or marked depression; >70: severe or extreme major depression Takes about 10 minutes to complete Scores provide indicative ranges for depression severity useful for clinical and research purposes Serves as a general gauge of depression and mood, but should not be used as a substitute for the clinical interview for confirming a diagnosis of depression Beliefs about the cause, prevention, and treatment of illness vary among cultures These beliefs dictate the practices used to maintain health, including folk, spiritual or psychic healing practices, and conventional medical practices Traditional cultural values differ from the dominant U.S. culture As health care providers, we are influenced by the cultural values with which we were raised & by the culture of medicine Assessment and treatment of depression must be culturally grounded and respect the values and beliefs of the individual and their culture Control over environment Change focus Time orientation Individualism/privacy Self-oriented Competition Achieved status Future orientation Directness Practicality/efficiency Traditional Cultures Fatalism Tradition focus Relationship orientation Collectivism Group welfare Cooperation Birthright ascribed status Past orientation Indirect Idealism/spiritualism Hall, 2002, adapted from Cross-cultural counseling: A guide for nutrition and health counselors. (1986).

8 Severity and symptoms of depression vary across cultures Sadness may lead to less concern than irritability in some cultures Hallucinations & delusions, which can be part of a Major Depressive Disorder, should be differentiated from cultural beliefs (e.g., fear of being hexed, feeling of being visited by those who have died) Latin American & Mediterranean cultures Depressive symptoms manifest as complaints of nerves and headaches Susto, tiredness, & weakness resulting from frightening & startling experiences (Hispanics) resemble symptoms suggesting a Major Depressive Disorder (Paniagua, 2000, p. 139) Asian cultures Depressive symptoms manifest as complaints of weakness, tiredness, or imbalance Middle Eastern & American Indian cultures Depressive symptoms manifest as complaints of difficulties with the heart or being heartbroken (Paniagua, 2000, p. 139)

9 Because late-life mental illness is so closely associated with functional disability, a functionally oriented comprehensive geriatric assessment is most likely to lead to optimal treatment Using a Comprehensive Geriatric Assessment to Improve Care: Baldwin, R. C. (2010). Depression in later life. New York, NY: Oxford University Press. Cuéllar, I., & Paniagua, F. A. (2000). Handbook of multicultural mental health. San Diego, CA: Academic Press. Karel, M. J., Ogland-Hand, S., Gatz, M., & Unützer, J. (2002). Assessing and treating late-life depression: A casebook and resource guide. New York, NY: Basic Books. Reuben, D. B., Herr, K. A., Pacula, J. T., Pollock, B. G., Potter, J. F., & Semla, T. P. (2012). Geriatrics at your fingertips (14 th ed.). New York, NY: American Geriatrics Society. [to be released April 2012] Zarit, S. H., & Zarit, J. M. (2007). Mental disorders in older adults: Fundamentals of assessment and treatment (2 nd ed.). New York, NY: The Guilford Press.