CHAMPCHAMPDepression in the Hospitalized Depression in the Hospitalized Older PatientOlder Patient

Joanna Martin, MDJoanna Martin, MDHorizon Hospice and Palliative Care, Horizon Hospice and Palliative Care,

ChicagoChicago

Mariko K Wong, MDMariko K Wong, MDUniversity of ChicagoUniversity of Chicago

Topics for discussionTopics for discussion

• Why should we screen inpatients for Why should we screen inpatients for depression and who is at risk?depression and who is at risk?

• Depression in the elderly can Depression in the elderly can present atypicallypresent atypically

• Review screening toolsReview screening tools• Discuss pharmacotherapyDiscuss pharmacotherapy• Planning for continuity after Planning for continuity after

dischargedischarge

Prevalence of DepressionPrevalence of Depression

• CommunityCommunity– 2% major, 10-30% depressive symptoms2% major, 10-30% depressive symptoms

• Outpatient SettingOutpatient Setting– 5-10%, 10-30% 5-10%, 10-30%

• Inpatient SettingInpatient Setting– 10-20%, 10-30%10-20%, 10-30%

• Long-term care settingLong-term care setting– 10%, 30%10%, 30%

Clinical Case OneClinical Case One

• 80 year old female with DM, Htn, and 80 year old female with DM, Htn, and OA, admitted from ER with insomnia, OA, admitted from ER with insomnia, headaches and weight loss (>5% of headaches and weight loss (>5% of body weight). body weight).

• PMH: DM, htn, history of PMH: DM, htn, history of ““anxietyanxiety””• Meds: HCTZ, metoprolol, metformin, Meds: HCTZ, metoprolol, metformin,

Lorazepam prnLorazepam prn• SH: lives alone, has a daughter that SH: lives alone, has a daughter that

checks in on herchecks in on her• Exam: anxious, otherwise normal examExam: anxious, otherwise normal exam

IsnIsn’’t depression an t depression an outpatient issue? outpatient issue?

Many older patients with depression are Many older patients with depression are “missed” in the outpatient setting“missed” in the outpatient setting•Up to one-half of all depressed elderly seen Up to one-half of all depressed elderly seen by primary care physicians are not identified by primary care physicians are not identified as depressedas depressed•In one study, 40% of depressed elderly In one study, 40% of depressed elderly patients attributed depression to “old age” patients attributed depression to “old age” and were much less likely to discuss with and were much less likely to discuss with their doctortheir doctor11

Why screen in the hospital?Why screen in the hospital?

Depressive symptoms in older, hospitalized Depressive symptoms in older, hospitalized patients increase risk for: patients increase risk for:

1.1. MortalityMortality

2.2. RehospitalizationRehospitalization

3.3. Functional DeclineFunctional Decline

Covinsky et al. Ann Intern Med. Covinsky et al. Ann Intern Med. 19991999

Association with MortalityAssociation with Mortality

3 year mortality is higher 3 year mortality is higher with ≥6 depressive with ≥6 depressive symptoms symptoms

(56% vs. 40%, hazard ratio (56% vs. 40%, hazard ratio = 1.56 [95% CI, 1.22-2]; = 1.56 [95% CI, 1.22-2]; p=0.001)p=0.001)

After adjustment for After adjustment for cofounders, hazard ratio cofounders, hazard ratio = 1.34 [CI, 1.03-1.73]= 1.34 [CI, 1.03-1.73]

Association with Hospital Association with Hospital ReadmissionReadmission

Depressive symptoms are associated with an Depressive symptoms are associated with an increased rate of hospital readmission (adjusted increased rate of hospital readmission (adjusted hazard ratio, 1.50; 95% CI 1.03-2.17; p=.03)hazard ratio, 1.50; 95% CI 1.03-2.17; p=.03)

Bula, C. J. et al. Arch Intern Med 2001;161:2609-2615.

Covinsky, K. E. et. al. Ann Intern Med 1997;126:417-425

Association with Functional Association with Functional DeclineDecline

Patients with ≥6 Patients with ≥6 depressive depressive symptoms & symptoms & dependent in ≥1 ADL dependent in ≥1 ADL were more likely to were more likely to have functional have functional decline:decline:•At discharge (OR At discharge (OR 3.23 CI 1.76-5.96)3.23 CI 1.76-5.96)•At 30d (OR 3.45 CI At 30d (OR 3.45 CI 1.81-6.60)1.81-6.60)•At 90d (OR 2.15 CI At 90d (OR 2.15 CI 1.15-4.0301.15-4.030

Depression in the Depression in the Hospitalized Patient – Why Hospitalized Patient – Why screen?screen?

• Can increase length of hospital stay Can increase length of hospital stay because slows recovery and because slows recovery and mobilizationmobilization

• Inpatient setting is a good time to make Inpatient setting is a good time to make a diagnosis and get referrals in placea diagnosis and get referrals in place

• Treatments are effective!Treatments are effective!

Crystal et al. JAGS 51(1718-1728, 2003Crystal et al. JAGS 51(1718-1728, 2003

Risk of Recurrence Risk of Recurrence

• Depression should be viewed as a chronic Depression should be viewed as a chronic illness, making identification even more illness, making identification even more importantimportant

• Recent randomized, double blind study Recent randomized, double blind study showed high risk of recurrence in older showed high risk of recurrence in older patients (NEJM 354;11)patients (NEJM 354;11)– Patients treated with SSRI were less likely to Patients treated with SSRI were less likely to

have recurrent depression have recurrent depression – Relative risk of recurrence among patients Relative risk of recurrence among patients

receiving placebo: 2.4 (95% CI 1.4 - 4.2)receiving placebo: 2.4 (95% CI 1.4 - 4.2)– Number needed to treat to prevent one Number needed to treat to prevent one

recurrence:recurrence: 4 (95% CI 2.3 - 10.9)4 (95% CI 2.3 - 10.9)

Reynolds et al. NEJM 2006;354:1130-8

Back to our clinical caseBack to our clinical case

• Husband passed away one year agoHusband passed away one year ago• Daughter reports the onset of wt Daughter reports the onset of wt

loss, insomnia and headaches at that loss, insomnia and headaches at that timetime

• She thought her mother might be She thought her mother might be ““downdown”” about her father about her father’’s death but s death but thought her momthought her mom’’s level of grief was s level of grief was appropriate and typical of her getting appropriate and typical of her getting olderolder

Who is at Risk?Who is at Risk?

• Female gender Female gender (gap narrows with (gap narrows with increasing age)increasing age)

• Divorced or Divorced or separated statusseparated status

• Low Low socioeconomic socioeconomic statusstatus

• Poor social Poor social supportssupports

• Comorbid illnessComorbid illness

• Cognitive Cognitive ImpairmentImpairment

• Adverse/Stressful Adverse/Stressful life eventslife events

• Family historyFamily history• Prior depressive Prior depressive

episodesepisodes• Prior suicide Prior suicide

attemptsattempts• Financial StressFinancial Stress

Associated Medical Associated Medical ProblemsProblems

• History of CVAHistory of CVA• CancerCancer• MIMI• Rheumatoid Rheumatoid

ArthritisArthritis• COPDCOPD

• ParkinsonParkinson’’s s DiseaseDisease

• Diabetes MellitusDiabetes Mellitus• DementiaDementia• Hip fracture / fallHip fracture / fall

Clinical Case TwoClinical Case Two

• 80 year old male with history of a stroke 80 year old male with history of a stroke one year ago, DM, Htn, admitted one year ago, DM, Htn, admitted through ER for mental status changes; through ER for mental status changes; patientpatient’’s son concerned about increased s son concerned about increased confusionconfusion

• SH: lives alone in assisted living, son SH: lives alone in assisted living, son sees once a weeksees once a week

• Exam: VSS, alert and interactive, some Exam: VSS, alert and interactive, some short term memory loss notable (MMSE short term memory loss notable (MMSE 23/30), low vision, stable mild right-23/30), low vision, stable mild right-sided weakness from old strokesided weakness from old stroke

Post-CVA DepressionPost-CVA Depression

• >30% of stroke victims >30% of stroke victims • Risk highest in first two years after a Risk highest in first two years after a

strokestroke• Within 10 years after a stroke, the risk Within 10 years after a stroke, the risk

of death is 3.5 times higher in of death is 3.5 times higher in depressed patientsdepressed patients**

**Am J Psychiatry 1993 Jan;150(1):124-9Am J Psychiatry 1993 Jan;150(1):124-9

DiabetesDiabetes

• Higher risk of developing depressionHigher risk of developing depression• Diabetic patients often have more Diabetic patients often have more

comorbid health problems i.e. painful comorbid health problems i.e. painful peripheral neuropathy, heart peripheral neuropathy, heart disease, vision loss etc.disease, vision loss etc.

• Consider routine screeningConsider routine screening

AlzheimerAlzheimer’’s Diseases Disease

• Depression occurs in up to 50% of Depression occurs in up to 50% of patients and can cause cognitive patients and can cause cognitive deficitsdeficits

• In the early stages, 10% of patients In the early stages, 10% of patients develop MDD; 30% develop develop MDD; 30% develop symptoms of minor depressionsymptoms of minor depression

• In severe dementia, 12% with MDD In severe dementia, 12% with MDD but probably an underestimatebut probably an underestimate

PseudodementiaPseudodementia

• Situation where patients seem Situation where patients seem demented but are actually depresseddemented but are actually depressed

• Patients who appear to demonstrate Patients who appear to demonstrate complete cognitive recovery with complete cognitive recovery with antidepressant treatmentantidepressant treatment

• Develop high rates of dementia (20% Develop high rates of dementia (20% per year)per year)

Atypical presentationAtypical presentation

• Older depressed patient often has Older depressed patient often has different complaints and different complaints and presentation than younger patients presentation than younger patients

• Less commonly experience Less commonly experience ““mood mood symptomssymptoms””

• Older patients often have more Older patients often have more somatic symptoms and may end up somatic symptoms and may end up hospitalizedhospitalized

Stewart. PGM. 2004;115(6)

Depression in older adults: Depression in older adults: what else to look for?what else to look for?

• Irritability, anxiety or decreased Irritability, anxiety or decreased functional capacity (in a hospital setting, functional capacity (in a hospital setting, this can confuse physicians and may this can confuse physicians and may prolong length of stay) prolong length of stay)

• Recognize that the role of coexisting Recognize that the role of coexisting medical problems, cognitive deficits, and medical problems, cognitive deficits, and multiple medications complicates the multiple medications complicates the picturepicture

• Many assume depression is a normal Many assume depression is a normal response to agingresponse to aging

BereavementBereavement

• Older patients are more likely to Older patients are more likely to experience significant lossesexperience significant losses

• Major depression should always be Major depression should always be treated as a serious illness even if treated as a serious illness even if precipitated by life circumstancesprecipitated by life circumstances

• Antidepressants have shown to Antidepressants have shown to benefit patients with bereavement-benefit patients with bereavement-related depressionrelated depression

Who should be screened? Who should be screened?

• Patients with commonly associated Patients with commonly associated medical conditions medical conditions

• Adverse life eventsAdverse life events• Physical signs and symptoms: pain, Physical signs and symptoms: pain,

insomnia, weight loss, fatigueinsomnia, weight loss, fatigue• Even if they do not complain of Even if they do not complain of

“feeling depressed”!“feeling depressed”!

Geriatric Depression Scale: Geriatric Depression Scale: Short FormShort Form

• 1. Are you basically satisfied with your life?1. Are you basically satisfied with your life?• 2. Have you dropped many of your activities and interests? 2. Have you dropped many of your activities and interests? • 3. Do you feel that your life is empty? 3. Do you feel that your life is empty?

4. Do you often get bored? 4. Do you often get bored? • 5. Are you in good spirits most of the time? 5. Are you in good spirits most of the time? • 6. Are you afraid that something bad is going to happen to you? 6. Are you afraid that something bad is going to happen to you? • 7. Do you feel happy most of the time? 7. Do you feel happy most of the time? • 8. Do you often feel helpless? 8. Do you often feel helpless? • 9. Do you prefer to stay at home, rather than going out and 9. Do you prefer to stay at home, rather than going out and

doing new things? doing new things? • 10. Do you feel you have more problems with memory than 10. Do you feel you have more problems with memory than

most? most? • 11. Do you think it is wonderful to be alive now?11. Do you think it is wonderful to be alive now?• 12. Do you feel pretty worthless the way you are now? 12. Do you feel pretty worthless the way you are now? • 13. Do you feel full of energy? 13. Do you feel full of energy? • 14. Do you feel that your situation is hopeless? 14. Do you feel that your situation is hopeless? • 15. Do you think that most people are better off than you are?15. Do you think that most people are better off than you are?

Sheikh et al. J Psychiatric Res 1983;17:37-49

More about GDSMore about GDS

• Probably the most widely accepted in older patientsProbably the most widely accepted in older patients• Takes about 5 minutes to complete, yes or no answers Takes about 5 minutes to complete, yes or no answers

(simple)(simple)• 92% sensitivity and 89% specificity, performs well in 92% sensitivity and 89% specificity, performs well in

inpatient settingsinpatient settings• Cons: Does not ask about sleep, somatic symptoms, or Cons: Does not ask about sleep, somatic symptoms, or

suicidal ideation. Not validated for treatment response.suicidal ideation. Not validated for treatment response.• Website with references, versions in multiple languages, Website with references, versions in multiple languages,

and apps for iphone/android:and apps for iphone/android:– http://www.stanford.edu/~yesavage/GDS.html

9-Item Patient Health 9-Item Patient Health Questionnaire (PHQ-9)Questionnaire (PHQ-9)

More abut PHQ-9More abut PHQ-9

• Not as well-validated as GDS in older patientsNot as well-validated as GDS in older patients• Sensitivity and specificity of 88%Sensitivity and specificity of 88%• Does ask about suicidality, and has been Does ask about suicidality, and has been

validated to assess for treatment responsevalidated to assess for treatment response• Cons: More complex for patients to answer, Cons: More complex for patients to answer,

especially those with cognitive impairmentespecially those with cognitive impairment

Screening Tools: Teaching Screening Tools: Teaching PointPoint

• Great opportunity to involve the Great opportunity to involve the medical students in plan of caremedical students in plan of care

• Can distribute GDS and encourage Can distribute GDS and encourage students to screen elderly patients at students to screen elderly patients at riskrisk

Medications AssociatedMedications Associated

• Antihypertensives agents are a cause of Antihypertensives agents are a cause of depressive symptoms in the geriatric depressive symptoms in the geriatric populationpopulation

-B-blockers (Atenolol has less of a CNS -B-blockers (Atenolol has less of a CNS effect)effect)

-Clonidine -Clonidine • AntiparkinsonAntiparkinson’’s meds (levodopa class) often s meds (levodopa class) often

cause depression as can Parkinsoncause depression as can Parkinson’’s disease s disease itself. itself.

• Others: benzos, propranolol, barbiturates, Others: benzos, propranolol, barbiturates, antihistamines antihistamines

Treatment: MedicationsTreatment: Medications

• SSRIs are somewhat interchangeable regarding SSRIs are somewhat interchangeable regarding effectivenesseffectiveness

• Choose an SSRI based on its side effect profile, Choose an SSRI based on its side effect profile, drug interactions and compliancedrug interactions and compliance– Citalopram and sertraline are often recommended Citalopram and sertraline are often recommended

among experts for efficacy and tolerability in the elderlyamong experts for efficacy and tolerability in the elderly– Paroxetine: anticholinergic properties and short half-life Paroxetine: anticholinergic properties and short half-life

making withdrawal more common when patients miss making withdrawal more common when patients miss dosesdoses

• Newer antidepressantsNewer antidepressants– Bupropion: usually activating Bupropion: usually activating – Mirtazapine: can increase appetite and improve sleepMirtazapine: can increase appetite and improve sleep– Duloxetine: improves painDuloxetine: improves pain

Treatment: Non-pharmTreatment: Non-pharm

• Cognitive behavioral therapy and Cognitive behavioral therapy and interpersonal therapy can be helpfulinterpersonal therapy can be helpful

• In the outpatient setting, RCT of In the outpatient setting, RCT of pharmacotherapy and brief pharmacotherapy and brief psychotherapy shown to be more psychotherapy shown to be more effective than usual care effective than usual care

• Emerging data showing physical Emerging data showing physical activity and exercise can be helpfulactivity and exercise can be helpful

Unützer et al. JAMA. 288(22)

Other TreatmentsOther Treatments

• Ritalin – can be used short term Ritalin – can be used short term

• ECT- may be treatment of choice in ECT- may be treatment of choice in patients with refractory, severe patients with refractory, severe depression or depression with depression or depression with psychosispsychosis

Clinical Case OneClinical Case One

• 80 year old female with htn, 80 year old female with htn, osteoarthritis, admitted from ER with osteoarthritis, admitted from ER with insomnia, headaches and some mild insomnia, headaches and some mild weight loss. weight loss.

• PMH: Htn, history of PMH: Htn, history of ““anxietyanxiety””• Meds: HCTZ, Lopressor, Lorazepam prnMeds: HCTZ, Lopressor, Lorazepam prn• SH: lives alone, has a daughter that SH: lives alone, has a daughter that

checks in on herchecks in on her• Exam: anxious, otherwise normal Exam: anxious, otherwise normal

examexam

Clinical Case OneClinical Case One

• More information: patient had lost More information: patient had lost her husband one year agoher husband one year ago

• Daughter had noticed decline every Daughter had noticed decline every since her father had died but thought since her father had died but thought it was just it was just ““old ageold age””

• Had missed several appointment Had missed several appointment with her outpatient PCPwith her outpatient PCP

• Screens positive on GDS with score Screens positive on GDS with score of 8/15of 8/15

Treatment Plan Treatment Plan

• Social Work referral made to DOASocial Work referral made to DOA• Plan made to wean patient off of Plan made to wean patient off of

lorazepam and changed BP medlorazepam and changed BP med• SSRI started in the hospitalSSRI started in the hospital• PatientPatient’’s PCP made aware of treatment s PCP made aware of treatment

plan with follow up soon after plan with follow up soon after hospitalizationhospitalization

• Referral to outpatient psychiatry and Referral to outpatient psychiatry and support group; daughter agreed to make support group; daughter agreed to make sure her mother got to appointmentssure her mother got to appointments

Clinical Case TwoClinical Case Two

• 80 year old male with history of a stroke 80 year old male with history of a stroke one year ago, DM, Htn, admitted through one year ago, DM, Htn, admitted through ER for mental status changes; patientER for mental status changes; patient’’s s son concerned about increased confusionson concerned about increased confusion

• SH: lives alone in assisted living, son sees SH: lives alone in assisted living, son sees once a weekonce a week

• Exam: VSS, alert and interactive, low Exam: VSS, alert and interactive, low vision, some short term memory loss vision, some short term memory loss notable (MMSE 23/30), stable mild right-notable (MMSE 23/30), stable mild right-sided weakness from old strokesided weakness from old stroke

Back to clinical case twoBack to clinical case two

• The patient was medically stable and The patient was medically stable and not deliriousnot delirious

• The patient screened positive (GDS The patient screened positive (GDS 10/15)10/15)

• ? depressive symptoms contributed to ? depressive symptoms contributed to cognitive deficitscognitive deficits

• PatientPatient’’s son educated about situations son educated about situation• Patient started on antidepressantPatient started on antidepressant• Outpatient follow-up Outpatient follow-up

Teaching points for the Teaching points for the wardswards

• Identify misconception that depression Identify misconception that depression is only an outpatient issueis only an outpatient issue

• Depression in the hospital is Depression in the hospital is associated with increased mortality, associated with increased mortality, rehospitalization, and functional rehospitalization, and functional decline decline

• Depression often has different Depression often has different presentation in the elderly – keep on presentation in the elderly – keep on the differentialthe differential

In summary . . .In summary . . .

• Screen for depression in geriatric Screen for depression in geriatric inpatients at risk inpatients at risk

• Recognize atypical presentations in Recognize atypical presentations in the elderlythe elderly

• Review medicationsReview medications• Initiate a treatment plan in house Initiate a treatment plan in house

and arrange for appropriate follow-upand arrange for appropriate follow-up

Bibliography: Page OneBibliography: Page One

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• Kroenke K et al. THE PHQ-2: Validity of a Two Item Depression Screener. Med Kroenke K et al. THE PHQ-2: Validity of a Two Item Depression Screener. Med Care. 2003 Nov;41(11):1284-92.Care. 2003 Nov;41(11):1284-92.

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