Evaluating Dimensions of

Transcription

1 Evaluating Dimensions of Geriatric Depression and Anxiety Joel E. Streim, MD Professor, Psychiatry Geriatric Psychiatry Section University of Pennsylvania VISN 4 MIRECC Philadelphia VA Medical Center Philadelphia, Pennsylvania

2 Faculty Disclosure: Joel E. Streim, MD Source National Institute for Mental Health (NIMH) VA HSR&D Health Resources and Services Administration (HRSA) National Institute on Aging (NIA) Grant / Research Support X X X X 2

3 Learning Objective Identify and evaluate the dimensions of geriatric depression and/or anxiety, using measurement-based principles

4 Dimensions of Geriatric Depression and Anxiety: Themes and Topics Key dimensions relevant to clinical assessment of elderly patients with depression and anxiety Approaches to assessment, with an emphasis on measurement tools Multidimensional assessment and Multidimensional assessment and measurement to facilitate individualized treatment

5 Why Is Multidimensional Assessment Important? Helps us individualize treatment - Pharmacotherapy - Learning-based psychotherapies By addressing morbidities that are associated with poorer treatment response and outcomes Anxiety Suicidal ideation Pain Sleep disturbance Nutritional compromise Executive dysfunction Katz et al. J Geriatr Psychiatry Neurol. 1993;6(3):

6 Key Dimensions of Assessment Baseline measures of depression and anxiety symptoms 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

7 Key Dimensions of Assessment (cont) Evaluation of psychosocial support Availability and quality of care giving Appraisal of patient and family attitudes toward treatment, including risk tolerance Likelihood of treatment engagement and adherence Barriers that require addressing Courtesy of Joel E. Streim, MD

8 Approaches to Assessment Focus on Common Presentations of Depression and Anxiety in Older Adults Caregivers may report irritability or hostility as the predominant affective disturbance 1 Other anxiety symptoms may be associated with depression 2 Worry Obsessive ruminations Panic symptoms Posttraumatic stress symptoms Somatic preoccupation/delusions 1. Monfort. Int Psychogeriatr. 1995;7(suppl): Lenze. Curr Psychiatry Rep. 2003;5(1):62-67.

9 Approaches to Assessment 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 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:

10 Approaches to Assessment Focus on Common Presentations of Depression and Anxiety in Older Adults (cont) Cognitive changes 1 Memory complaints Executive dysfunction not solely attributable to impaired concentration ti Functional decline Disengagement from usual activities 2 not solely attributable to anhedonia Impaired performance of activities of daily living 3 not solely attributable to loss of interest Self-neglect 3 not solely attributable to hopelessness or giving up Poor oral intake 4 not solely attributable to loss of appetite 1. Lockwood et al. Am J Psychiatry. 2002;159: Tsai et al. J Chin Med Assoc. 2009;72(9): Pavlou, Lachs. J Gen Intern Med. 2008;23(11): Patel, Martin. J Nutr Health Aging. 2008;12(4):

11 Benefits of Standardized Measurement Severity of symptoms (eg, anxiety, pain) has prognostic value 1 PHQ-9 and GAD-7 are sensitive to treatment effects over time 1,2 Dimensional measures can inform care management/individualized care 1 Objective evidence of treatment benefits can be used to support patient adherence 2 PHQ-9, Patient Health Questionnaire-9; GAD-7, Generalized Anxiety Disorder Roman, Callen. Issues Ment Health Nurs. 2008;29(9): Roy-Byrne et al. J Am Board Fam Med. 2009;22(2):

12 Tool Kit of Standardized Assessment Instruments Please see your handouts for more detailed descriptions of these tools PHQ-9 GAD-7 Geriatric i Depression Scale (GDS) Hospital Anxiety and Depression Scale (HADS) Paykel Suicide Scale PTSD checklist AUDIT-C Bi Brief fpain Inventory Short-form McGill Pain Questionnaire-2 (SF-MPQ-2) Pittsburgh Sleep Quality Index (PSQI) Barthel Index

13 Mrs Sensperanza s PHQ-9 9Score PHQ, Patient Health Questionnaire n/dep_tool_05.pdf. Accessed January 21, 2010.

14 PHQ-9 Scoring for Depression Severity Total Score Depression Severity 0-4 No depression 5-9 Mild Moderate Moderately severe Severe Mrs Sensperanza s score is: 13 Kroenke et al. J Gen Intern Med. 2001;16(9):

15 Mrs Sensperanza s GAD-7 7Score GHD-7, General Anxiety Disorder Questionnaire Permission i pending.

16 GAD-7 Scoring for Anxiety Severity GAD-7 Total Score Anxiety Severity 0-4 Minimal 5-9 Mild Moderate Severe Mrs. Sensperanza s score is: 18 Spitzer et al. Arch Intern Med. 2006;166:

17 Recognition of Executive Dysfunction History of observable functional and behavioral signs 1 Difficulty with initiation Inability to perform sequential tasks Poor task completion Disengagement from activities Task avoidance (BADL, IADL) Referral for evaluation of functional status by occupational therapist 2 1. Alexopoulos. J Clin Psychiatry. 2003;64(suppl 14): Erez et al. Am J Occup Ther. 2009;63(5):

18 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 Adherence Response Tolerability Identifies comorbidities to be addressed by care management/ learning-based psychotherapies Targets problem areas that require family and caregiver support for treatment