Assessment and Treatment of Depression in Late Life

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Assessment and Treatment of Depression in Late
Life

• Sarra Nazem
• Jay Gregg
• Patty Bamonti
• West Virginia University

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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!

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Depression in Late Life
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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

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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 gt psychological symptoms
• Comorbidity

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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

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Special populations

• Rates of depression are higher in some groups
• Medical inpatients 10-15
• Nursing home residents 14-42

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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

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How does it differ for older adults?

• Depression without sadness
• More likely to endorse or exhibit
• Forgetfulness/difficulty concentrating
• Psychomotor retardation
• Psuedodementia

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Medical conditions and late-life depression

• Stroke
• Cardiovascular disease
• Vascular depression
• Parkinsons disease
• COPD

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Depression and Dementia

• Depression of Alzheimers Disease
• Social withdrawal
• Irritability
• Dementia and Vascular depression
• Vegetative symptoms

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Comorbid Psychological Disorders

• Anxiety
• Substance Abuse
• Insomnia

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Substance abuse

• Underestimated problem!
• Alcohol, prescription drugs, tobacco abuse most
  common
• Drinking problems not noticed until
• Dependence on others
• Interacts with medical illnesses/treatment
• Whats normal/acceptable?
• Medication issues

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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, cant metabolize drugs
• Problems falls, impotence, delirium, dementia,
  dehydration, gait problems, drug interactions

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Demographics Etiology

• Men 2x women, 15 problem drinkers
• Prescriptions drugs women
• Ethnicity needs to be studied
• Etiology?
• Same as younger adults
• Late-onset environment gt genetics

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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

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

• Attempt to death ratio 41 (overall 251)
• Female to male attempt ratio 32
• (overall 31)
• Risk factors
• Chronic illness
• Decreased social support
• Late life depression
• Others?
• Gender differences
• Race/Ethnicity differences

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Assessment
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Who is at risk?
Previous episode of depression
Severe stressors
Chronic general medical conditions
Substance dependence issues
Family history
Being female
Loss of independent functioning
Acutely disabling conditions
Physical disability
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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

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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

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Multidimensional Assessment

• Adaptive functioning
• Physical health
• Diseases, Medications
• Cognitive functioning
• Social support

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Case Example Kevin

• Besides assessing for depression, what other
  factors would you want further information on?
• How might Kevins lack of social support play a
  role in his depression?

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Multi-Method Assessment

• Self-report
• Report-by-others
• Clinician rating
• Direct observation

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Case Example Susan

• How would you handle this situation?
• Why might Susans report differ from the staff
  report?

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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

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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

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Assessment Strategy

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

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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 lt 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

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Suicide Assessment

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

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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

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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
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Treatments for Late Life Depression
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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?

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What psychotherapies have been validated in older
adults?

• Traditional Cognitive Behavior Therapy (CBT)
• Problem-Solving Therapy (PST)
• Interpersonal Therapy (IPT)

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What psychotherapies have been validated in older
adults in the treatment of depression?

• Cognitive Behavior Therapy (CBT)
• Goal Increase patients 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.

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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.

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Event Tracking
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Mood Tracking
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What are the active ingredients of these
therapies?

• CBT
• Cognitive Restructuring
• Introduce what negative thoughts are and how
  they relate to an individuals 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

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3-Column
Situation Thoughts Consequences or Emotions
Describe the situation or event that led to your unpleasant emotions Write down the negative thoughts and/or negative self talk that occurred in connection with this experience. Rate how strongly you believe in these thoughts 0-100. Write down what you were feeling during this experience (anxious, angry, sad, etc.) Rate how strong your emotions are from 0-100.
6-Column
Situation Thoughts Consequences or Emotions Develop adaptive response Effect Function
_____ _____ _____ Challenge negative thoughts Impact of changing thoughts What can you do in the future?
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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 Im an old woman,
  theres nothing left for me. When asked about
  what she likes to do for enjoyment, she states
  that Theres no point in going out, I wont 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 cant 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?

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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.

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What are the active ingredients of these
therapies?

• PST
• Problem orientation- a set of relatively stable
  cognitive-affective schemas that represent a
  persons generalized beliefs, attitudes, and
  emotional reactions about problems in living and
  ones ability to cope with problems.
• Positive problem orientation
• Negative problem orientation

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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

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Case Example

• Define problem
• Generate alternative solutions
• Decision making
• Implementation and evaluation

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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.

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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.

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Interpersonal problems in older adulthood

• What are some interpersonal problems likely to
  be encountered in older adulthood?
• How could IPT-based strategies be used to help
  the patient manage them?

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How can these therapies be adapted to patients
with cognitive impairment or dementia?

• Home practice can be enhanced with audiotapes or
  videotapes.
• Simplified home practice forms to make them
  easier to understand.
• For cognitive aspects of treatment, introduce
  fewer concepts, repeat them often, and reinforce
  them continuously.
• Use cues and recognition to facilitate the
  patients new learning of skills.
• Pleasant Event Schedule designed for patients
  with dementia.
• Have caregivers engage in assisting the older
  adult patient in participating in pleasurable
  activities.

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How can treatments be adapted to include
co-morbidities, such as substance use, chronic
pain, and/or insomnia?

• Chronic pain
• CBT (10-week group sessions) reduced chronic
  pain ratings and pain-related disability in
  nursing home residents when compared to residents
  who received supportive therapy.
• Improvements maintained after 4 months.
• Focused on education and reconceptualization of
  pain, behavioral and cognitive coping skills
  (progressive muscle relaxation, imagery,
  cognitive restructuring).
• Other strategies distracting oneself,
  pleasurable events, and calming self-statements.
• Mindfulness and acceptance therapies

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How can treatments be adapted to include
co-morbidities, such as substance use, chronic
pain, and/or insomnia?

• Brief interventions
• Occur in one or more sessions and include
• Feedback based on screening questionnaires
  related to drinking, other substance use,
  smoking, and nutrition.
• Discussion of the types of drinkers in the U.S.
  and where the patients drinking fits relevant to
  his/her age group.
• Reasons for drinking.
• Consequences of drinking.
• Reasons to reduce or eliminate drinking.
• Drinking limits or strategies for reducing or
  eliminating alcohol use.
• Drinking agreement (e.g. contract).
• Coping with risky situations (e.g. social
  events).
• Additional approaches
• Family/friends involvement
• Motivational interviewing
• Based on the Substance Abuse Among Older Adults,
  Treatment Improvement Protocol (TIP) Series 26
  DHHS Publication No. (SMA) 98-3179 , Printed
  1998.

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How can treatments be adapted to include
co-morbidities, such as substance use, chronic
pain, and/or insomnia?

• Insomnia
• CBT-I
• Psycho-education
• Sleep compression/sleep restriction
• Stimulus control
• Cognitive distortions
• Sleep hygiene

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Helpful Resources

• Alexopoulos, G.S. et al. (2008). Problem solving
  therapy for the depression-executive dysfunction
  syndrome of late life. International Journal of
  Geriatric Psychiatry, 23, 782-788.
• Arean, P.A. Cook, B.L. (2002). Psychotherapy
  and Combined Psychotherapy/Pharmacotherapy for
  Late Life Depression. Society of Biological
  Psychiatry, 52, 293-303.
• Gallagher-Thompson, D. Thompson, L.W. Treating
  Late-Life Depression A Cognitive-Behavioral
  Therapy Approach (2010).
• Satre, D.D., Knight, B.G., David, S. (2006).
  Cognitive-behavioral interventions with older
  adults integrating clinical and gerontological
  research. Professional Psychology Research and
  Practice, 37, 489-498.

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Questions? Comments?

• Sarra.Nazem_at_mail.wvu.edu
• Jeffrey.Gregg_at_mail.wvu.edu
• Patricia.Bamonti_at_mail.wvu.edu